The University of Utah purchased a 100-clinician, 9-practice multispecialty primary care network in 1998. The university projected the network to earn a profit the first year of its ownership in a market with growing capitation; however, capitation declined and the network incurred up to a $21 million operating loss per year. This case study describes the financial turnaround of the network.
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.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
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.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
Read Logica’s paper on the need for convergence of healthcare and pharmaCGI
As the biggest industry sector in most European economies, healthcare is already given a big chunk of the gross domestic product (GDP). This portion is expected to become even bigger and have a huge impact on employment, the opportunities to grow businesses and economies in general.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Read about some of the innovative solutions we offer for better healthcareCGI
Delivering healthcare is one of the most complex human activities. In recent decades, major transitions have taken place in diagnostics, pharmaceuticals and treatments resulting in shorter length of stay in healthcare facilities. The current transition to more personalised care and to longer term managed care pathways means that healthcare IT systems are changing direction. But this change may not happen smoothly.
Patient Safety in Indian Ambulatory Care settings By.Dr.Mahboob ali khan PhdHealthcare consultant
Despite the fact that the vast majority of health care takes place in the outpatient, or ambulatory care, setting, efforts to improve safety have mostly focused on the inpatient setting. However, a body of research dedicated to patient safety in ambulatory care has emerged over the past few years. These efforts have identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.
Intro to informatics pharmacist by Linus LayLinus Lay
Presented by Linus Lay, Pharm.D. Candidate from the University of Rhode Island Class of 2022.
This presentation was in-service to RxInsider, a B2B multimedia publishing and technology company for the "business of pharmacy." Pharmacy Informatics is a rising field in the specialties of pharmacy. This presentation provides a brief background on the responsibilities of an informatics pharmacist, short history of the specialty curriculum, and the current education for the field of informatics for student pharmacists.
View MyCred Portfolio: https://mycred.com/p/2929377185
View Youtube Video: https://youtu.be/WTi2ldztl2I
Talks On the Hill about the ACA and Primary care transformation by : Kevin Grumbach, University of California, San Francisco; Paul Grundy, IBM; Craig Jones, Vermont Blueprint for Health; and Jeffrey Schiff, Minnesota Department of Human Services. Melinda Abrams of The Commonwealth Fund and Ed Howard of the Alliance co-moderated.
Read Logica’s paper on the need for convergence of healthcare and pharmaCGI
As the biggest industry sector in most European economies, healthcare is already given a big chunk of the gross domestic product (GDP). This portion is expected to become even bigger and have a huge impact on employment, the opportunities to grow businesses and economies in general.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Read about some of the innovative solutions we offer for better healthcareCGI
Delivering healthcare is one of the most complex human activities. In recent decades, major transitions have taken place in diagnostics, pharmaceuticals and treatments resulting in shorter length of stay in healthcare facilities. The current transition to more personalised care and to longer term managed care pathways means that healthcare IT systems are changing direction. But this change may not happen smoothly.
Patient Safety in Indian Ambulatory Care settings By.Dr.Mahboob ali khan PhdHealthcare consultant
Despite the fact that the vast majority of health care takes place in the outpatient, or ambulatory care, setting, efforts to improve safety have mostly focused on the inpatient setting. However, a body of research dedicated to patient safety in ambulatory care has emerged over the past few years. These efforts have identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.
Intro to informatics pharmacist by Linus LayLinus Lay
Presented by Linus Lay, Pharm.D. Candidate from the University of Rhode Island Class of 2022.
This presentation was in-service to RxInsider, a B2B multimedia publishing and technology company for the "business of pharmacy." Pharmacy Informatics is a rising field in the specialties of pharmacy. This presentation provides a brief background on the responsibilities of an informatics pharmacist, short history of the specialty curriculum, and the current education for the field of informatics for student pharmacists.
View MyCred Portfolio: https://mycred.com/p/2929377185
View Youtube Video: https://youtu.be/WTi2ldztl2I
Talks On the Hill about the ACA and Primary care transformation by : Kevin Grumbach, University of California, San Francisco; Paul Grundy, IBM; Craig Jones, Vermont Blueprint for Health; and Jeffrey Schiff, Minnesota Department of Human Services. Melinda Abrams of The Commonwealth Fund and Ed Howard of the Alliance co-moderated.
PCMH implementation, highly associated with important outcomes for both patients and providers. The rate of emergency department visits was significantly
lower in sites with more PCMH effective implementation. Efficient PCMH implementation favorably associated with patient satisfaction, staff burnout, quality of care, and use of health care services.
The PCMH is a reality in 16 primary care practices in Colorado that have participated in one of the nation’s first Multi-Payer, Multi-State Patient-Centered Medical Home Pilots, along with stakeholders at both local and national levels. Convened by HealthTeamWorks, the project began in 2008 and runs through 2012.
Why Emplyers care about Pimary care 2008Paul Grundy
Employers are beginning to recognize that investing in the primary care foundation of the health care system may help address their problems of rising healthcare costs and uneven quality. Primary care faces a crisis as a growing number of U.S. medical graduates are avoiding primary care careers because of relatively low reimbursement and an unsatisfying work life. Yet a strong primary care sector has been associated with reduced health care costs and improved quality. Through the and other efforts, some large employers are engaged in initiatives tostrengthen primary care. [Health Affairs 27, no. 1 (2008): 151–158;
A systematic review of the challenges to implementation of the patient-centre...Paul Grundy
review the available literature to identify the major challenges and barriers to implementation and adoption of the patient-centred medical home (PCMH) model, topical in current Australian primary care reforms. documents the key challenges and barriers to implementing the PCMH model in United States family practice. It provides valuable
evidence for Australian clinicians, policymakers, and
organisations approaching adoption of PCMH elements
within reform initiatives in Australia.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
Care by design 2 bodenheimer teams 2 utah chapterPaul Grundy
Putting Care back into healthcare the University of Utah experience in building PCMH level care. this talks about the team base experice as written up in 2007 by Tom Bodenheimer.
Copyright 2014 American Medical Association. All rights reserv.docxdickonsondorris
Copyright 2014 American Medical Association. All rights reserved.
Compensation of Chief Executive Officers
at Nonprofit US Hospitals
Karen E. Joynt, MD, MPH ; Sidney T. Le, BA; E. John Orav, PhD; Ashish K. Jha, MD, MPH
H ospital chief executive officers (CEOs) play a criticalrole in shaping the performance of their organiza-tions through setting organizational priorities, allo-
cating resources, and hiring clinical leadership. Indeed, in a
recent large national survey1 of hospital board chairpersons,
respondents reported that CEOs were the single most influ-
ential individuals in shaping quality performance at their
institutions.
One way to potentially improve quality at an institution
is to tie the CEO’s compensation to the institution’s perfor-
mance. This has been broadly used in other industries, and data
suggest that metrics chosen for inclusion in CEO compensa-
tion packages can affect executives’ behavior.2,3 However, we
know little about how CEOs in the hospital industry are paid
and the specific factors that underlie their compensation, with
much of the data either decades old or focused on a limited
sample of institutions.4-8 These issues are particularly salient
among nonprofit institutions, in which the metric of organi-
zational success in many industries—the profitability of the or-
ganization—must be balanced against more mission-driven fac-
tors, such as the quality of care delivered and the degree of
community benefit provided. Yet, we are unaware of any em-
pirical data on the metrics by which CEOs of nonprofit hospi-
tals are paid or to what degree the hospital’s quality of care or
level of community benefit affects their compensation.
In mid-2012, national data on compensation of CEOs of
nonprofit entities became publicly available for the first time.
We used these newly available data to answer 3 questions. First,
IMPORTANCE Hospital chief executive officers (CEOs) can shape the priorities and
performance of their organizations. The degree to which their compensation is based on their
hospitals’ quality performance is not well known.
OBJECTIVE To characterize CEO compensation and examine its relation with quality metrics.
DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study. Participants
included 1877 CEOs at 2681 private, nonprofit US hospitals.
MAIN OUTCOMES AND MEASURES We used linear regression to identify hospital structural
characteristics associated with CEO pay. We then determined the degree to which a hospital’s
performance on financial metrics, technologic metrics, quality metrics, and community
benefit in 2008 was associated with CEO pay in 2009.
RESULTS The CEOs in our sample had a mean compensation of $595 781 (median, $404 938)
in 2009. In multivariate analyses, CEO pay was associated with the number of hospital beds
overseen ($550 for each additional bed; 95% CI, 429-671; P < .001), teaching status
($425 078 more at major teaching vs nonteaching hospitals; 95% CI, 315 238-534 918;
P.
A Case Study forBecky Skinner, RRT, BSSpecialized Care Coo.docxevonnehoggarth79783
A Case Study for
Becky Skinner, RRT, BS
Specialized Care Coordinator
University of Iowa Hospitals and Clinics
May 30, 2013
UIHC Human Capital Strategies to Comply and Thrive Under The Patient Protection Affordable Care Act Regulations
Table of Contents
Mission & Vision 3
History of the University of Iowa Hospitals & Clinics 4
Fiscal Year 2012 Facts 4
Statement of Problem or Challenge 5
Research and Background Data 7
Implications PPACA Has on UIHC Human Capital Management 11
Resolution Proposal 14
Summary and Conclusion 17
Appendix A: SWOT Analysis 19
Appendix B: Corporate Parenting Strategy 27
Appendix C: Portfolio Analysis 35
References 45
History of the University of Iowa Hospitals & ClinicsVision:
World Class People.
· Building on our greatest strength.
World Class Medicine.
· Creating a new standard of excellence in integrated patient care, research and education.
For Iowa and the World.
· Making a difference in quality of life and health for generations.Mission:
Simply stated, our mission is: Changing Medicine. Changing Lives.®
University of Iowa Health Care is changing medicine through Pioneering discovery
· Innovative inter-professional education
· Delivery of superb clinical care
· An extraordinary patient experience in a multi-disciplinary, collaborative, team-based environment
University of Iowa Health Care is changing lives by
· Preventing and curing disease
· Improving health and well-being
· Assuring access to care for people in Iowa and throughout the world
In 1873 The University of Iowa began providing medical services when it reached an agreement with Sisters of Mercy to operate a small hospital in the area. It began with two wards, one for women and the other for men containing four private rooms and a surgical amphitheater. In 1865 this agreement was terminated when the Sisters of Mercy moved across town and opened up Mercy Hospital. Today, the University of Iowa Hospitals and Clinics is a public -teaching hospital affiliated with the University of Iowa and a Level 1 trauma center. It has 711 beds including a 190-bed UI Children’s Hospital (About Us, n.d.). On an average day, there are close to 9,000 individuals providing care to patients, including employees, students and volunteers (About Us, n.d.). Fiscal Year 2012 Facts
There were 32,000 patients admitted to the hospital for in-patient care with 59,000 emergency room visits. In the 200 outpatient clinics of the UIHC, 977,337 clinic visits were counted. In addition to the 1,300 volunteers of UIHC, it employed during FY2012:
· 1,548 physicians, residents, and fellows
· 8,221 non-physician employees of whom 1,845 are professional nurses (About Us, n.d.)
Since U.S. News & World Report began to rank hospitals in 1990, UIHC has made the list as one of the best and has over 271 physicians ranked as “Best Doctors in America”.
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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 ...
Health Care Reform (The Affordable Care Act) .docxisaachwrensch
Health Care Reform (The Affordable Care Act)
“
ANA believes that health care is a basic human right (ANA, 1989, ANA, 1998, ANA 2005). Thus, ANA reaffirms its support for a restructured health care system that assures universal access to a standard package of essential health care services for all citizens and residents.”
“ANA believes that the development and implementation of health policies that reflect the six Institute of Medicine (IOM) aims (Safe/Effective/Patient-centered/Timely/Efficient/Equitable) and are based on outcomes research will ultimately save money.”
“The system must be reshaped and redirected away from the overuse of expensive, technology-driven, acute, hospital-based services in the model we now have, to one in which a balance is struck between high-tech treatment and community-based and preventive services, with emphasis on the latter. The solution is to invert the pyramid and focus more on primary care, thus ultimately requiring less costly secondary and tertiary care.”
Activity:
Please read the attached Health Policy Brief on Basic Health Program and “Nursing’s Role in healthcare reform” from American Nurse Today.
Please go to
www.rnaction.org
, go to the Take Action tab above to access the following information regarding health care reform and the new Affordable Care Act. Scroll down the page to the heading Resources and Supreme Court Challenge to learn more about the health care reform and how it affects you as a nurse and as an individual with a family. Check out all the different information.
HealthCare.gov
Keeping health care reform healthy, patients informed
New Animation Explains Changes Coming for Americans Under Obamacare
(7/13)
Health Care Transformation: The Affordable Care Act and How it Affects Nurses
(3/12)
Health Care Reform Legislation Timeline
ANA Policy and Provisions of Health Reform Law
National Conference of State Legislatures Health Reform Site
Kaiser Family Foundation Health Reform Page
The Supreme Court Decision Matters for Registered Nurses, their Families, and their Patients
ANA Analysis: Supreme Court Arguments on the ACA
ANA to Supreme Court: ‘Individual Mandate’ Needed to Make Health Reform Work
Then proceed to the Kaiser Foundation to watch the following:
http://kff.org
““Health Care Reform Hits Main Street on the Kaiser Foundation website or Youtube. (2010)
“New Animation Explains Changes Coming to Americans under Obamacare” (2013) Youtube or Kaiser Foundation
“
Health insurance Explained: YouToons Have it Covered”
(
2014) Youtube or Kaiser Foundation
If you would like more information regarding the ACA, the Kaiser Foundation is a great source and cover many issues.
http://kff.org
Link:
http://kff.org/health-reform/press-release/new-animation-explains-changes-coming-for-americans-under-obamacar.
Submission Id ab299d7c-b547-4cf3-958a-07922ca71f2765 SIM.docxdeanmtaylor1545
Submission Id: ab299d7c-b547-4cf3-958a-07922ca71f27
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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.
By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docxclairbycraft
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/.
By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docxjasoninnes20
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/ ...
While the cost of living in an assisted living community is often a shock to perspective residents, it is important to understand the value proposition of any facility you are considering to fully appreciate what your money is paying for. At United Methodist Communities, our non-profit, faith based mission insures that the costs of your care, pay for your care, and not corporate profits. Visit https://umcommunities.org/
The tertiary care hospital utilization of the balanced scorecard Nancy Southerland
The tertiary care hospital has as its primary responsibility to deliver health care to the most sick and severely ill. The management of the critically ill is seen as a wrathful driver of costs within the confines of the tertiary care hospital both in the United States and abroad. Through utilization of the Balanced Scorecard not only are the needed financial metrics elevated but the added dimensions of customer (both internal and external), internal business processes, and learning and growth dimensions are part of the balanced scorecard perspectives. Through use of the balanced scorecard in the tertiary care hospital, the wrath of the cost driver of the therapeutic management and intervention of the critically ill is assuaged. Tertiary care hospitals are able to deliver solid operating margins while ensuring patient satisfaction with good clinical outcome of the critically ill while experiencing much employee engagement. The tertiary care hospital enjoys the interconnectedness of the dimensions realizing quickly that over time all the Balance Scorecard perspectives are financial dimensions.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
"'I am proud that MaineCare has been working in partnership with other payers to advance payment reform through greater investment in primary care to both improve outcomes for patients and reduce preventable high cost spending in emergency departments and avoidable inpatient admissions.
– Mary C. Mayhew, Commissioner, Maine Department of Health & Human Services
Effective integration of specialty practices into medical neighborhoods is likely to require several important environmental precursors. First, a sound infrastructure
design can connect PCMHs to the spectrum of surrounding
specialty practices. An aligned information architecture
will be vital to adequate patient access, care coordination, and communication. Second, a patient centered
neighborhood will rely on an organizational culture that
supports shared learning and transparency of performance and cost data among participating practices. Third, payment incentives will have to be aligned around shared accountability for outcome and cost. Responsibility
for outcomes and total cost of care will have to rest not only with primary care clinicians, but also with specialists who perform(often expensive) procedures and specialty services.The launch of the NCQA’s PCSP recognition program is a sign of a new phase of delivery system reform
Summary -- Patient Centered Medical Home the Necessary Foundation for Accountable Care and Population Management.
In the next 10 years, we will be living in 1) mobile world 2) in the middle of an aging and chronic disease epidemic and 3) data. But , we will also have the ability to analyze data in a cognitive way this will do for doctors’ minds what X-ray and medical imaging have done for their vision. How? By turning data into actionable information. Take, for instance, IBM’s intelligent supercomputer, Watson. Watson can analyze the meaning and con-text of human language and quickly process vast amounts of information. With this in-formation, it can suggest options targeted to a patient’s specific circumstances.
We need the basic foundation to support this transformation a system integrator where data at the level of a patients flows and is held accountable and that model is the Patient Centered Medical Home. (PCMH) starts to happen when clinicians/ healers step up to comprehensive relationship based care empowered by tools to manage the data and communicate effectively. This move to PCMH level care requires the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system and all of that is power by data made into meaningful information.
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military and under the ACA.
OVERVIEW -- Care by Design - Putting Care back into healthcare the University of Utah experience in building PCMH level care over the decade of 2001 to . 2011
New zealand cantabury timmins-ham-sept13Paul Grundy
This is a great example of a community in New Zealand of the interrogation of social services and healthcare. They are changing the demand curve and getting away from “we need more and more resources to see more patients”. The language we use, very deliberately, is “right care, right place, right time”. Once you start getting the whole
system to work as one system, it starts flushing out unnecessary expenditure. So you can do more and/or do it better.’ worth a read.
I did a visit to new zealand in 2003 and did a number of talks from 2003 to 2005 on the transformation taking place in new zealand. back in NZ in 2014 so looked at those early slide so impressed with the leadership and the robust primary care
, patients reported higher overall satisfaction at a primary care practice that adopted the patient-centered medical home model along with lean process changes and physician payment reform.
.......................................................................................................
South central foundation Alaska
If you are in a mechanical manufacturing environment then hitting a target is a matter much like the throwing of a rock – figuring out speed trajectory
If you are in a messy, human, complex, adaptive environment it is like throwing a
bird at a target – it is all about the ‘attractor’
Healthcare mostly throws birds at targets and only thinks about the throwing part than wonders why the Human fails to hit the target
Partial and Incremental PCMH Practice Transformation: Implications for Qualit...Paul Grundy
Experience of BCBS Michigan in Building medical homes
Based on the observed relationships for partial implementation,full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population.
Conclusions. Estimated effects of the PCMH model on quality and cost of care
appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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CASE STUDY
Successful Turnaround of a University-
Owned, Community-Based, Multidisciplinary
Practice Network
ABSTRACT
PURPOSE The University of Utah purchased a 100-clinician, 9-practice multi-
specialty primary care network in 1998. The university projected the network
to earn a profit the first year of its ownership in a market with growing capita-
tion; however, capitation declined and the network incurred up to a $21 million
operating loss per year. This case study describes the financial turnaround of
the network.
METHODS In 2001, the university reconfigured the practices for a fee-for-
service environment while preserving the group’s multidisciplinary clinical
and ancillary services. Changes included reorganization under the exist-
ing University of Utah Hospitals and Clinics system, new governance and
leadership, closure of practices, creation of a billing office, new financial
reporting, implementation of electronic health records, revision of physician
compensation, capture of referrals, leadership and staff training, and practice
reengineering.
RESULTS The network as a whole became profitable in 2004-2005. Its primary
care component is projected to become profitable in 2 to 3 years. The network is
opening new sites strategically important to the health system.
CONCLUSIONS This turnaround required commitment from senior university
leaders, management with knowledge of primary care practice, retention of
ancillary revenues, and management and business services specific to the net-
work with support from other units within the university. Culture change within
the group was essential. Our experience suggests that an academic health cen-
ter can successfully operate a primary care network by attending to the unique
needs of this challenging business. Doing so can strengthen the institution’s
overall financial and clinical performance and provide an important setting for
teaching and research.
Ann Fam Med 2006;4(Suppl 1):S12-S18. DOI: 10.1370/afm.540.
INTRODUCTION
M
any academic health centers (AHCs) restructured in the
1990s in response to competitive markets and declining
reimbursement.1-6
Some purchased or built primary care
practice networks, with disappointing results. Although some AHCs
have reported changes leading to recovery of their health system as
a whole,1-4
few have reported transforming major financial losses of
university-owned, community-based outpatient systems into stable or
profitable systems.
This report describes one such financial turnaround of a university-
owned, community-based, multidisciplinary practice network.
Michael K. Magill, MD1,2,3
Robin L. Lloyd, MPA3,4
Duane Palmer, MBA3
Susan A. Terry, MD2
1
Department of Family and Preventive
Medicine, University of Utah School of
Medicine, Salt Lake City, Utah
2
Community Physician Group, University
of Utah Hospitals and Clinics, Salt Lake
City, Utah
3
Community Clinics, University of Utah
Hospitals and Clinics, Salt Lake City, Utah
4
Ambulatory Services, University of Utah
Hospitals and Clinics, Salt Lake City, Utah
Conflicts of interest: none reported
CORRESPONDING AUTHOR
Michael K. Magill, MD
375 Chipeta Way, Suite A
Salt Lake City, UT 84108
Michael.Magill@hsc.utah.edu
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METHODS
Setting
In 1998, the University of Utah purchased a 100-
clinician multispecialty and primary care system with
9 outpatient practices remote from the university in
the Salt Lake City metropolitan area, now known as
the University of Utah Community Clinics. The uni-
versity purchased the network with savings (“develop-
ment accounts”) generated by faculty members in the
school of medicine that, although university property,
were generally perceived as faculty resources to use
for research, sabbaticals, and other purposes. The pur-
chase price of $37.4 million represented approximately
50% of the development account balances. Projected
profit from the network in the first year of university
ownership was expected to provide a return on invest-
ment to the development accounts. At the time of pur-
chase, 34% of the Salt Lake County population were
aged 19 years or younger, and 8% were aged 65 years
or older. Seventy-five percent of the revenue of the
purchased practices was derived from capitated health
insurance payments. Profitability was projected based
on expected growth in capitated payments.
Initial Management
The practice network was organized in the university
as a business unit separate from the school of medicine
and the University Hospital and Clinics, but was not
incorporated separately from the university. It was gov-
erned by a board of directors, composed primarily of
school of medicine department chairs and led by a cen-
tral executive group. Central medical practice admin-
istration included 8 executive full-time equivalents
(FTEs), and the medical practice network (not count-
ing health plans or imaging) included about 87 FTE
clinicians and 629 FTE staff. The network operated
3 major subunits: the medical practices themselves,
a health plan, and a separate radiology practice. The
practices were physician based for Medicare billing
purposes. This report describes the medical practices
and related ancillary services only.
Initial Results
The practice network generated immediate losses,
peaking at more than $21 million on approximately
$80 million in revenue in fiscal year 2000. Capitation
decreased throughout the market. Lacking operating
capital, the system drew on university reserves.
Organization of the network as a separate univer-
sity business unit hindered effective collaboration with
other university medical administrators and physicians
to recognize and correct problems. Because the pur-
chased group had provided largely capitated care, its
billing, collection, and financial reporting capabilities
were inadequate for fee-for-service practice. Physicians
were paid salary without productivity incentives. Most
inpatient and specialty referrals were sent to nonuni-
versity physicians and hospitals.
In 1999, a new university president and a new Vice
President for Health Sciences/Dean of the School of
Medicine, along with the board of regents and univer-
sity trustees, faced a critical decision: whether to sell
the network at a loss, writing off debt to the university
and to faculty development accounts, or to restructure
the network for profitability and to support the larger
system by generating high-margin referrals. The former
risked serious, lasting damage to the health system’s
market position. The latter posed a high risk of failure.
Data Sources
Information reported here about financial performance
of the system came from internal management reports.
Information about interventions to improve perfor-
mance was derived from management records and par-
ticipants’ recollections.
Authors’ Perspective
We authors helped lead the changes described herein.
Dr Magill has been chairman of the Department of
Family and Preventive Medicine at the University of
Utah School of Medicine since before purchase of the
network. Because of the relative size of reserves, his
department was the second largest contributor of funds
for the purchase. He served on the network’s initial
board of directors, before being appointed chairman
of the reorganized board and then chief executive offi-
cer (CEO). Mr Lloyd joined the University of Utah in
2002. He had previously managed hospital-affiliated
primary care practices and had spent 6 years consulting
with hospitals to turn around failing primary care net-
works. Mr Palmer and Dr Terry implemented changes in
the clinic operations and physician group, respectively.
Changes
Changes in the community clinics have occurred
in 3 overlapping phases, outlined in Table 1 and
described below.
Phase I: Draconian Change
Initial reorganization took about 2 to 3 years and
entailed closing and relocating some of the exist-
ing practices. Administrative restructuring included
appointment of a new board of directors, chairman/
CEO, and senior management. The community clin-
ics were moved under the administrative structure of
the University of Utah Hospitals and Clinics. These
changes led to layoffs of approximately 130 people,
including executive staff (reduced from 8 FTEs to the
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current 2.75 FTEs), physicians,
and about 18% of the workforce.
Summary statistics on sites, staff-
ing, visits, and active patients are
shown in Table 2.
A new management structure
paired a physician leader with an
administrator at each of 3 levels.
The full-time CEO position was
divided into a part-time execu-
tive medical director position
and a full-time executive director
position. Within the community
clinics, a medical director and
administrative director report to
the executive medical director
and executive director. Each clinic
network is led by a team of a
medical director and a clinic man-
ager, who are jointly accountable
for its performance. The evolving
profile of the clinics is summa-
rized in Table 2. Current staffing
is shown in more detail in Table 3.
Through the restructuring,
the network retained certain fea-
tures. In addition to primary med-
ical care, the practices’ ancillary
services are included in network
financial statements. Each practice
includes full-service pharmacy,
radiology, optician, and optical
dispensing services. The system
operates other services as shown
in Table 4, many of which are not
typically included in university-
owned practice systems limited
only to primary care, but which
were purchased as an integrated
unit and are still operated as such.
The network mandated that referrals to specialists and
hospitals outside the network be to the university.
Phase II: Innovation and Performance Improvement
After the more severe changes initiated in the first
phase, network leadership initiated the second, ongo-
ing phase of culture change, operational improve-
ment, clinical quality improvement, control of costs,
and increase in revenue. A critical step in this process
was to develop management and physician productiv-
ity reports specific to the needs of ambulatory prac-
tices. The practices were converted to hospital (“pro-
vider”) based for Medicare billing purposes. Another
step was to implement an incentivized physician
Table 1. Operational Changes Implemented in University of Utah
Community Clinics, 2000-2005
Phase of Change
(Approximate Time) Examples of Changes
I: Draconian change
(years 1-2)
Restructure organization, governance, and leadership
Restructure financing
Achieve “right size”: match capacity to demand, close practices not
suited to fee for service or for referrals to the university
II: Innovation and
performance
improvement
(year 3 onward)
Develop financial and management reports
Revise physician compensation and benefits to incentivize produc-
tivity and sustainable levels
Implement correct core principles of successful group practices
• Focus on patient experience
• Match the right person to the right job
• Standardize procedures
• Design facilities for efficiency and patient service
• Exploit technology
• Improve communication
Redesign ambulatory practice operations
• Implement advanced access scheduling
• Reengineer the ambulatory visit to be patient centered and
physician efficient
• Strive for lean design
Implement robust electronic medical record through all clinics
Establish an active clinical quality improvement program
Develop new services and new practice sites
III: Integration with the
academic mission
(year 4 onward)
Teaching
• Appoint physicians as adjunct faculty to the school of medicine
• Standardize educational contracts with outside institutions
• Allow elective rotations for students (medical, physician’s assis-
tant, other) and residents
• Offer a continuity clinic for pediatrics residents
• Integrate outpatient family medicine residency/faculty clinics
in to community clinics network
Research
• Establish a research oversight committee: health sciences cen-
ter faculty, community clinics physicians and staff
• Develop principles and oversight for research: select research
that enhances the practices without disrupting operations
• Track projects and direct research expense using community
clinics (total to date approximately $2.5 million)
• Establish formal practice-based research networks:
Utah Health Research Network, Utah Sports Research Network
Table 2. Summary Profile of University of Utah
Community Clinics, 1998-2005
Characteristic 1998 2000 2005
No. of primary medical
practice sites
9 8 7
Total clinician FTEs 87 79 70
Physician FTEs
Midlevel clinician* FTEs
NA
NA
64
15
61
9
Staff FTEs 629 516 483
No. of patient visits NA 216,430 263,605
No. of active patients NA NA 105,300
FTE = approximate full-time equivalents; NA = data not available.
* Physician’s assistants (PAs), nurse-practitioners (NPs), and certified nurse-
midwives (CNMs).
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compensation system rewarding productivity at a
level sustainable for the long term. A third step entails
continued and repeated education for leadership,
management, and clinicians.
Phase III: Integration With the Academic Mission
Although the major focus has been on business per-
formance of the clinics, they were also gradually
integrated into the academic mission of the university.
Growth of teaching in the practices has been gradual,
as students and residents from multiple programs in
the university and from elsewhere discover the oppor-
tunity to learn in these practices.
Growth of research has been more directed, with
oversight from a joint committee of university faculty
from multiple health professions schools along with
physicians and management from the clinics. Research is
selected based on its benefit to the practices and patients,
and is managed in a way so as not to disrupt practice
operations. In addition, practice innovations and clinical
quality improvements developed at 1 site in the network
can rapidly disseminate throughout the system. Table 5
summarizes research conducted to date in the clinics.
RESULTS
The financial performance of the community clinics
improved steadily, as shown in Figure 1. The clinics
were profitable in the fiscal year ending June 2005.
Profitable individual service lines were specialty care,
pharmacy, laboratory, and optical services (Table 6).
The remaining service line, primary care, is projected
to become profitable in 2 to 3 years.
Separate from the network’s direct income and
expenses, other University of Utah specialist physicians
and University Hospital generated more than $5 mil-
lion gross revenue per month from referrals originating
in the network.
DISCUSSION
This report describes the successful financial turn-
around over 5 years of a university-owned multidisci-
plinary outpatient clinical care system. As is typical
for strategic change across industries, the turnaround
occurred in phases to reduce cost, to reorganize opera-
tions, and to incorporate academic missions.7-9
Lessons Learned
Lessons learned from this experience include the
following:
1. “Yagottawanna.” Motivation to fix the problem
was present at all levels: the university had to either
accept a substantial reduction in its reserves or cor-
rect the system to generate margin in a fee-for-service
market. Senior university leaders needed to be patient
Table 3. Employees of University of Utah
Community Clinics, 2005
Employees No.*
Clinicians†
121
Main staff clinicians
Family medicine
Internal medicine
Pediatrics
Internal medicine/pediatrics
Obstetrics-gynecology
Gastroenterology
Podiatry
Physical medicine
Occupational medicine
Physical therapy
63
28
11
7
2
5
2
2
1
1
4
Other clinicians 58
Ski clinic (seasonal) 12
University of Utah visiting specialists 10
Moonlighters 29
Optometrists 7
Support staff 483
Total employees 604
* Numbers shown refer to individuals, not full-time equivalents.
† Medical doctors (MDs), doctors of osteopathy (DOs), doctors of physical
medicine (DPMs), physician’s assistants, nurse-practitioners (NPs), and certified
nurse-midwives (CNMs).
Table 4. Clinical and Business Services Provided
Within University of Utah Community Clinics, 2005
Clinical Services Business Services
Primary care
Family medicine, internal medicine,
pediatrics, obstetrics-gynecology
Specialty care
Gastroenterology, cardiology,
orthopedics, podiatry, neurol-
ogy, dermatology, urology, phys-
ical medicine and rehabilitation
Urgent care
Vision
Ophthalmology, optometry, optical
Pharmacy
Laboratory
Radiology
Plain radiography, CT, mammog-
raphy,
nuclear medicine, US
Travel clinic and infectious disease
Endoscopy
Physical therapy
Ski clinic
DEXA scan
Administrative
Executive leadership
Executive medical
director
Executive director
Chief operating officer
Group medical director
Clinic medical directors
Clinic management team
Support services
Central billing services
Marketing
Compliance
Payer contracting
Facilities management
Human resources
CT = computed tomography; US = ultrasound; DEXA = dual-energy x-ray
absorptiometry.
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with the process of improvement and
stand firm in their decisions despite sub-
stantial anger from faculty and criticism
in the press. A primary care physician
faculty member and a dedicated prac-
tice management executive believed in
the potential for the system and its vital
importance to the university, and were
committed to succeeding. Senior leader-
ship with expertise specific to the man-
agement of outpatient practices, as well
as committed to and accountable for the
success of the project is essential.
2. “You must reward productivity,
but it’s not all about productivity.” A
physician incentive system, set to reward
physicians’ productivity at sustainable
levels, is important. Equally important
in the longer term is a commitment to
redesigning the clinical practice opera-
tion to support physician success by
providing robust clinical and financial
information systems, adequate staff sup-
port, and efficient, patient-centered care.
Examples of key elements of practice
Table 5. Research Projects Using Community Clinics, 2000-2005
Project Title
PI’s/Coinvestigator’s Home
Department (School of Medicine)
or Other College Funding Source
Total Direct
Costs, $
Cutaneous Measures of Diabetic Neuropathy Internal Medicine NIH 1,345,705
Time to Pregnancy in Normal Fertility Family and Preventive Medicine NIH 499,995
Impact of Electronic Reminders on Screening for
Colon Cancer
Huntsman Cancer Institute, Family
and Preventive Medicine
NIH 247,500
The Safety Check Family and Preventive Medicine NIH, AHRQ 200,000
Pharmacological Mechanisms of Falls and Sway
in the Elderly
College of Nursing National Institute of
Nursing Research
150,000
Genital Herpes Prevention Study Internal Medicine NIH, industry 100,000
Insulin Glargine Treatment Patterns in the Manage-
ment of Diabetes, Type I and Type II
College of Pharmacy Industry 65,000
Effects of Various Drugs on Hypoglycemic Events College of Pharmacy Industry 65,000
Chronic Back Pain Anesthesiology Foundation 50,000
Bioterrorism Surveillance Family and Preventive Medicine Foundation 35,000
Determinants of Exercise in Obese and Nonobese
Sedentary Pregnant Women
Family and Preventive Medicine Department of Family and
Preventive Medicine’s
Small Grants Program
25,000
Asthma Guideline Adherence: Implications for Cost College of Pharmacy Department of Pediatrics 25,000
Measurement and Prevalence of Deformational
Plagiocephaly
Pediatrics, Family and Preventive
Medicine
AHRQ 20,000
Population Surveillance to Detect an Epidemic Family and Preventive Medicine Foundation 20,000
ADHD Patient Weight Distribution Study College of Pharmacy Industry 10,000
Developing a Research Tool to Accurately Measure
Latinos’ Perceived Barriers to Health Care
Family and Preventive Medicine Foundation 5,600
Other – – 12,500
Total direct costs of research using community
clinics
– – 2,876,300
PI = principal investigator; NIH = National Institutes of Health; AHRQ = Agency for Healthcare Research and Quality; ADHD = attention deficit/hyperactivity disorder.
Figure 1. Financial bottom line (profit or loss) of University
of Utah Community Clinics.
Millionsofdollars
-25
-20
-15
-10
-5
0
5
-$21,612,351
-$20,206,412
-$7,259,485
-$4,077,756
-$1,723,520
$244,000
FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
FY = fiscal year.
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redesign include robust electronic medical records and
financial information systems developed specifically
for outpatient practices. In addition, the organization
should provide adequate staff support and engineer
practices for efficient, patient-centered care with fea-
tures such as advanced access10
and lean design.11
3. “This ain’t your grandfather’s hospital clinic.”
Community-based practice requires internal opera-
tions and information different from those required
by a hospital or its specialty clinics. A network is
unlikely to succeed with separate functional depart-
ments typical in hospitals or with administrative
divisions between staff clinicians. Interdisciplinary
teamwork and integrated leadership and management
are essential.
4. “You can’t cost cut your way to profitability. The
game is won on the revenue side.” Hospitals typically
impose overhead expenses higher than those carried
by independent physician practices. Primary care
requires adequate volume to generate profit above the
large component of fixed costs.
5. “Don’t take away the profitable services and
then blame the system for its losses.” Primary care
practice generates more profit from procedural and
ancillary services than from evaluation and manage-
ment services. University-owned systems should
allow primary care systems to retain revenues from
procedural and ancillary services as part of an inte-
grated system. While this approach may reduce the
apparent “multiplier effect” of downstream revenue,
it does so by retaining within the practice network
services and accompanying revenues that are often
located elsewhere.12
6. “Plan from the beginning for the practice
network to become a ‘laboratory and classroom.’”
As part of academic institutions, these practices are
excellent resources for research and teaching, par-
ticularly when the practices incorporate full-featured
electronic medical records. Universities have as part
of their missions the development of new approaches
to patient care. These practices can be useful sites
for innovation in practice design and operation,13
for
quality improvement, and for research to character-
ize illness in primary care, as well as for more tradi-
tional clinical trials. Also, with translational research
increasingly recognized as essential,14
practice-based
research networks such as this one are critical to the
2-way exchange of learning along the continuum
between the laboratory bench and improved quality
of patient care.15
As medical practice becomes increasingly based
in ambulatory settings, these practice networks give
universities teaching sites away from the increasingly
rarified atmosphere of the academic health center.
Also, university ownership may provide more reliable
access to such sites as private practices under increas-
ing financial pressures become less available.
Leadership by medical school faculty committed to
excellence in primary care, such as faculty in a depart-
ment of family medicine, can help make the business,
clinical, and academic agendas of the practice network
mutually reinforcing.
Limitations
This report describes only 1 health care system. Cir-
cumstances specific to its purchase, its mix of services,
its operating strengths and weaknesses, and the mar-
ket may make the described events less applicable to
other settings. This report was written by individuals
accountable for results and directly involved in devel-
oping and implementing the turnaround plans. Other
observers might have identified different issues and
described the changes differently. Because this inter-
vention was complex and multidimensional and had no
control group, it is not possible to determine the rela-
tive impact of individual changes on the outcome.
Future Directions
We continue to improve volume, revenue, quality,
access, and patient satisfaction. This system improve-
ment is tied to a rapid increase in research and teach-
ing in the network and its full integration into all mis-
sions of the academic health center.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/4/suppl_1/s12
Key words: Financial performance; economics; fee for service; aca-
demic health centers; health care systems; organizational change; pri-
mary care; organization and administration
Table 6. Income Statement ($000) by Service Line, Fiscal Year 2005 (July 2004 to June 2005)
Measure
Primary
Care
Specialty
Care
Central
Laboratory Pharmacy
Vision
Services
Central
Administration Total
Total net revenue (loss) 16,884 9,537 2,335 24,214 2,922 (321) 55,570
Total expense 21,125 6,016 1,228 19,599 2,554 4,825 55,347
Net income (loss) (4,241) 3,521 1,106 4,616 368 (5,146) 224
Note: Values do not add exactly because of rounding.
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Submitted September 22, 2005; submitted, revised, January 20, 2006;
accepted January 30, 2006.
Portions of this material have been presented at meetings of the Asso-
ciation of Departments of Family Medicine, February 2004, San Diego,
Calif; the Society of Teachers of Family Medicine, May 2004, Toronto,
Ontario; the American Medical Group Association, March 2005, Los
Angeles, Calif, and September 2005, Chicago, Ill; and the Association of
American Medical Colleges, November 2005, Washington, DC.
Acknowledgments: The authors thank the senior leadership of the
University of Utah and the University of Utah Hospitals and Clinics, and
board members, physicians, and staff of the University of Utah Com-
munity Clinics for sponsoring and implementing the changes necessary
to accomplish the results described herein. Thanks to Richard Murdock
for comments on the text and to Mary McFarland for assistance with the
literature review.
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