1 Cancer Care Workforce Challenges: Can System Changes Enhance Survivorship Care? Tracy Gosselin, PhD, RN, AOCN Associate Chief Nursing Officer Ambulatory

Cancer Care Workforce Challenges: Can System Changes Enhance Survivorship Care?

Tracy Gosselin, PhD, RN, AOCNAssociate Chief Nursing OfficerAmbulatory Services & OncologyDuke University Health System

June 25, 2015

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All Rights Reserved, Duke Medicine 2011

Headlines Say – More Nurses Needed

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DRIVERS OF CHANGE

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IOM – Crossing the Quality Chasms

• Better care for individuals:– Safety– Effectiveness– Patient-centeredness – Timeliness– Efficiency– Equity

IOM. (2001). Crossing the Quality Chasm.


IOM - Ensuring Quality Cancer Care through the Oncology Workforce

• By 2020 81% increase in people living with or surviving cancer

• 14% increase in the number of oncologists• Shortage areas

– Allied health care professionals– Advanced practice providers– Nurses– Social workers– Others

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IOM. (2009). Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century


IOM - The Future of Nursing: Leading Change, Advancing Health

• Four key messages:– Nurses should practice to the full extent of their

education and training.– Nurses should achieve higher levels of education

and training through an improved education system that promotes seamless academic progression.

– Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.

– Effective workforce planning and policy making require better data collection and an improved information infrastructure.

IOM. (2010). The Future of Nursing: Leading Change, Advancing Health.


IOM – Delivering High-Quality Cancer Care

• Trends - aging population, workforce shortages, reliance on family caregivers and direct care workers, rising cost of cancer care, complexity of care, and limitations in tools to improve quality

• 10 Recommendations– Coordinated team based care

• Goal 3 – members of the cancer care team should coordinate with each other and with primary/geriatrics and specialist care teams to implement patients’ care plans and deliver comprehensive, efficient, and patient-centered care

– Core competencies for the workforce• Goal 4 – all individuals caring for patients should have appropriate

core competencies

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IOM. (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.


IOM – Delivering High-Quality Cancer Care – Recommendation 3

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• Federal and state legislative and regulatory bodies should eliminate reimbursement and scope-of-practice barriers to team-based care

• Academic institutions and professional societies should develop interprofessional education programs to train the workforce in team-based cancer care and promote coordination with primary/geriatrics and specialist care teams

• Congress should fund the National Workforce Commission


IOM – Delivering High-Quality Cancer Care – Recommendation 4

• Professional organizations that represent clinicians who care for patients with cancer should define cancer core competencies for their membership

• Cancer care delivery organizations should require that the members of the cancer care team have the necessary competencies to deliver high-quality cancer care, as demonstrated through training, certification, or credentials

• Organizations responsible for accreditation, certification, and training of non-oncology clinicians should promote the development of relevant core competencies across the cancer care continuum

• The US Dept. of HHS and other funders should finance demonstration projects to train family caregivers and direct-care workers in relevant core competencies related to caring for cancer patients

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Other Drivers Impacting Care Delivery• Meaningful Use

– Use of certified HER– Improve quality, safety, efficiency and disparities – meds, allergies,

smoking status– Improve care coordination

• Patient satisfaction/experience– Interactions, culture, perception/s, continuum of care– Clinician and Group Consumer Assessment of Healthcare

Providers and Systems (CG CAHPS)– Hospital Consumer Assessment of Healthcare Providers and

Systems(HCAHPS)• CMS Triple Aim

– Improve patient experience of care (includes quality and satisfaction)

– Improve the health of population– Reducing the per capita cost of health care

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Beryl Inst; Triple Aim Concept Design. 2009.


Scope of Practice Overlap between Registered Nurses (RN) and Physicians

Category of activities Specific activities that overlap

Physical exam Assessing vital signs such as measuring pulse, blood pressure, respiratory rate, temperature, and oxygen saturationAuscultating lung, heart, and abdominal soundsAssessing cranial nervesAssessing eyes and ears using ophthalmoscope and otoscopeTesting vision and hearingPerforming breast examTesting range of motion and muscle strength of upper and lower extremitiesAssessing pain

Health assessment Obtaining health history Administering screening tests (e.g., domestic violence, depression)Performing in person or telephone triage to determine need for further careIdentifying emergent complications, expected, or adverse response to medical treatment (e.g., a RN monitors blood pressure after administration of blood pressure lowering medication or monitors for bleeding after surgery)Identifying epidemiologic trends (e.g., a school RN notes sudden increase in flue cases and notifies health department of the changes in population health trend changes)

Medical diagnosis No overlap

Prescribing diagnostic tests and pharmacological treatments

No overlap

Category of activities Specific activities that overlap

Implementing treatments Administering medicationsCollecting blood, urine, stool samplesObtaining sputum and wound culturesProviding mental health and addiction counselingProviding health counseling related to management of chronic diseasesCoordinating careProviding wound careInserting foley catheter and nasogastric tube Inserting peripheral intravenous catheterObtaining 12-lead electrocardiogram (ECG)

Djukic & Kovner. 2010. Overlap of Registered Nurses and Physician Practice: Implications for U.S. Health Care Reform. Policy, Politics, & Nursing Practice 11(1).


Medicare Beneficiaries and Chronic Conditions

DAAAAAaA

CMS. (2012). Chronic Conditions.


Care Redesign

• Care in the US is suboptimal with some patients not receiving care at the right place or time

• Our health care system is fragmented and has barriers to how patients access care

• Care is not coordinated across the care continuum • Resources are inefficient and mechanisms to

currently provide care can often be redundant or missing

Hassett, MJ, et al. (2014).


WORKFORCE TRENDS


Future of the Nursing Workforce

• Nationally, the change in RN supply between 2012 and 2025 is projected to outpace demand.

• Approximately 2.9 million RNs were active in the workforce in 2012. Consistent with standard workforce research methodology, the Health Workforce Simulation Model assumes that the RN demand in 2012 equals the RN supply.

• Assuming RNs continue to train at the current levels and accounting for new entrants and attrition, the RN supply is expected to grow by 952,000 full-time equivalents (FTEs) – from 2,897,000 FTEs in 2012 to 3,849,000 FTEs in 2025 – a 33 percent increase nationally.

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http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf


Future of the Nursing Workforce

• The nationwide demand for RNs, however, is projected to grow by only 612,000 FTEs – from 2,897,000 FTEs in 2012 to 3,509,000 FTEs in 2025 – a 21 percent increase.

• The number of new graduates that entered the workforce has substantially increased from approximately 68,000 individuals in 2001 to more than 150,000 in 2012 and in 2013.

• While not considered in this study, emerging care delivery models, with a focus on managing health status and preventing acute health issues, will likely contribute to new growth in demand for nurses, e.g., nurses taking on new and/or expanded roles in preventive care and care coordination.

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http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf





Other Team Members

• Demand for oncology services to grow 42% with only 28% growth in supply of oncologists by 2025 (-1,500)

• Nurse educators• Social workers approximately 1,200• Pharmacists • Laboratory technicians• Radiology technicians• Registrars

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ICAN 2004-2005; http://www.asco.org/practice-research/cancer-care-america#recommendationshttp://www.ashp.org/DocLibrary/MemberCenter/SPPM/2013-ASHP-Staffing-Survey.pdf

http://bhpr.hrsa.gov/healthworkforce/reports/clinicallab.pdf


STRATEGIES

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Oncology Nursing Society

• Mission– To advance excellence in oncology nursing and quality

cancer care

• Incorporated July 17, 1975• Headquarters Pittsburgh, PA• Reduced dues for student nurses • Reduced dues for early career professional• Support for National Student Nurses Association• Local chapter support (225)

– Partner with local colleges/universities– Scholarships – Meeting attendance

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Oncology Nursing Society

Advocacy endeavors– ONS Director of Health Policy – Alec Stone– Hill Day events– ONS Capital Gang

• participating in Capitol Hill lobbying days• meeting with members of Congress and their staff• attending federal agency meetings• reviewing and providing input on draft legislation on

proposed regulations• representing ONS at press conferences or other public

meetings

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Oncology Nursing Society – Priority 1

Preserve and promote oncology nurses’ practice to the full scope of their ability.• To accomplish this top priority, ONS closely supports the

recommendations of the Institute of Medicine in its landmark report, The Future of Nursing: Leading Change, Advancing Health

• Nurses should practice to the full extent of their education and training.• Nurses should achieve higher levels of education through an improved

education system that promotes seamless academic progression• Nurses should be full partners with physicians and other healthcare

professionals in redesigning health care• Effective workforce planning and policy making require better data

collection and information infrastructure

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https://www.ons.org/advocacy-policy/priorities

http://www.thefutureofnursing.org/IOM-Report

http://www.thefutureofnursing.org/IOM-Report


Oncology Nursing Society - Priority 2

Improve the quality of cancer care. • Ensure that inpatient and outpatient quality measures used are

meaningful, relevant, and promote quality cancer care• Quality Improvement Registry – CMS approved with QCDR and

PQRS• Identify opportunities related to medical homes, accountable

care organizations, and other emerging healthcare delivery models

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https://www.ons.org/advocacy-policy/prioritieshttps://www.medconcert.com/content/medconcert/ONSQIR/


Oncology Nursing Society – Priority 3

Advocate for payment models that incorporate the work of oncology nurses and positively impact oncology practice.• Ensure adequate reimbursement of nursing care in CMS

processes to develop chronic care management codes and payment schedules

• Impact decision making and rules for the Centers for Medicare and Medicaid Services (CMS) value-based purchasing initiatives

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https://www.ons.org/advocacy-policy/priorities


Title VIII – Nursing Workforce Reauthorization Act

• In existence five decades• Representatives Lois Capps (D-CA) and David Joyce

(R-OH) reintroduced H.R. 2713– Maintain funding at FY15 of $232 million

• Entry level to graduate education• Largest source of federal funding for nursing

education– Financial support for nursing education

programs– Individual students– Nurses

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FY06-12 450,000

https://www.aamc.org/advocacy/hpnec/ http://www.rnaction.org/site/PageNavigator/nstat_take_action_title_viii_issues.html

https://www.aamc.org/advocacy/hpnec/

https://www.aamc.org/advocacy/hpnec/

http://www.rnaction.org/site/PageNavigator/nstat_take_action_title_viii_issues.html

http://www.rnaction.org/site/PageNavigator/nstat_take_action_title_viii_issues.html


CMS Graduate Nurse Demonstration Project• Mandated by section 5509 of the Affordable Care Act• 2012 call for application

– More community based training sites– More nurse practitioners

• Five sites awarded– Duke University Hospital in Durham, N.C.– Hospital of the University of Pennsylvania in Philadelphia, Penn.– Memorial Hermann-Texas Medical Center Hospital in Houston, Texas– Rush University Medical Center in Chicago, Ill.– Honor Health (formerly Scottsdale Healthcare Medical Center) in Scottsdale,

Ariz.

• Four year initiative, wrap up 2017• Evaluation by American Institute Research• Presentation to Congress

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http://innovation.cms.gov/initiatives/gne/


CMS Graduate Nurse Demonstration Project• Focuses on

– Primary care– Preventative care– Transitional care– Chronic care management– Other services appropriate to Medicare beneficiaries

• Post graduation– Non hospital based setting– Rural communities

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http://innovation.cms.gov/initiatives/gne/


2015 Nursing Workforce Study

• National Council of State Boards of Nursing & National Forum of State Nursing Workforce Centers

• Focus on supply of nurses• Sample

– RNs & LPNs– 260,000 of 4.5 million licensed (5.8%)

• Paper or web based survey– June to September

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Advanced Practice Registered Nurse (APRN)

• Full practice authority– Limited by state regulations – not uniform– Limited by provider

• 21 states plus DC permit nurse practitioners (NP) to diagnose, treat and prescribe without physician oversight

• 7 states require physician oversight of NP prescribing• 22 states require oversight of diagnosis, treatment, and prescribing• Payer policies• Consensus Model for APRN Regulation: Licensure, Accreditation,

Certification and Education - Endorsed by ONS and ONCC• North Carolina – Modernizing Nursing Practice Act (SB 695/HB 807)

– Regulatory, supervisory & oversight requirements

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https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfhttp://www.ncnurses.org/practice/docs/OptimizingNurseRolespaper2015-06.pdf

http://www.nihcr.org/PCP-Workforce-NPs


Traditional Career Path for the New Graduate Nurse

Med/SurgHospital

Ambulatory Care Setting

Specialty Field

According to a study by Kovner, Brewer, Fairchild, Poornima, Kim & Djukie (2007), of the over 3,000

newly licensed RN’s comprised in 35 states and

the District of Columbia, approximately 85% began their careers in acute care settings while less than 4%

entered the workforce in outpatient or ambulatory

settings.


Workforce Development & Support to Improve Survivorship Care

• Prelicensure ambulatory rotations • Professional Nursing Student Internship• Curriculum• Ambulatory oncology nursing residency programs• Scope of Practice• Post graduate fellowship program for nurse practitioners• Leveraging technology• Collaboration & Partnerships

– Primary Care – Business development– Colleges/schools

• Burnout/compassion fatigue

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Conclusion

• Collaboration across stakeholder groups

• Modernization of Nurse Practice Acts

• Funding for entry and advanced practice education

• Discovery and funding for innovative models of care

Documents

1 Cancer Care Workforce Challenges: Can System Changes Enhance Survivorship Care? Tracy Gosselin, PhD, RN, AOCN Associate Chief Nursing Officer Ambulatory