Workshop P

Advanced Practices – Planning, Implementing & Sustaining a Full-Service,

On-Site, Employee Health Clinic

3:00 p.m. to 4:15 p.m.

Biographical Information

Cynthia R Skeens MS, RN, COHN-S Employee Health and Wellness Manager

Dayton Children’s Hospital One Children’s Plaza, Dayton, Ohio 45404

937-641-3505 Fax: 937-641-6190 skeensc@childrensdayton.org

Cindy has been in the field of occupational health nursing for over 25 years. She began her career as a wellness specialist for Libbey Owens Ford in 1990. She then went on to become a Supervisor and later the Director of an Occupational Health Clinic at Springfield Mercy Hospital for 17 years. In this role she grew the clinic that provided services to area companies. In 2008, she moved on to be the Director of Occupational and Employee Health Services for The Ohio State University Wexner Medical Center. At OSU, Cindy ran the employee health services for over 17,000 employees and managed the occupational health clinic that serviced various area companies. In 2013, she left OSU and moved to her current role as the Employee Health and Wellness Manager at Dayton Children’s Hospital. There she oversees the on-site health clinic for employees and spouses, manages the wellbeing program for over 2200 employees, manages workers’ compensation and takes an active role in employee safety. Cindy holds a Bachelors of Science in Nursing from the University of Toledo and received her Masters of Science degree from the University of Michigan. She became a certified occupational health nurse specialist in 1993. Cindy shared this same presentation at the American Association of Occupational Health Nurses National Conference in April 2016 and it was very well received.

Presented by Cynthia Skeens MS, RN, COHN‐SEmployee Health and Wellness Manager

Planning, Implementing, and Sustaining an On-Site Clinic:

Areas to Address and Lessons Learned.

Today’s Objectives

1. Learn what to consider and address when planning for and opening a full service on site employee health clinic.

2. Learn about the importance of data collection and sharing the data as a means of determining the success of the clinic and validating its existence.

Dayton Children’s Hospital

• Located in Dayton, Ohio• 155 Beds• 6,321 inpatient admissions• 292,746 total visits• 79,330 Emergency Department visits• More than 2,000 employees• 9 outpatient centers• 45 key specialties (9 new)

Dayton Children’s Hospital

Expanding services and footprint—

• Opening a new 8 story tower in Spring 2017 

• Opening full service off site facility to include outpatient surgery, free standing ER, Urgent Care and Physician offices.   

Areas of Opportunities

• Rising cost of medical insurance expense– Employer-paid premium continue to rise– Cost to employees, specifically lower wage earners– Delayed treatment, due to cost

• Integrated occupational health, employee/spouse health & wellness, disease management, leave management

• Greater access; same day & walk-in appointments

Areas of Opportunities

• Reduction in lost time for select medical services

• Expanded offerings and vendor partnerships

• Increased employee engagement

• Ancillary spin-off potentials for lab, imaging, pharmacy

Our Why

The health of our employees at Dayton Children’s is equally important as the patients our employees care for every day.

Provide a convenient, accessible, low‐cost option for employees to receive care for minor illnesses and injuries, 

right here on Dayton Children’s campus. 

Research Support

• Watson Wyatt Benefits Consulting Group-– For employers, on-site clinics can mean gains in worker productivity

and lower health insurance outlays. “A clinic serving a couple thousand employees can probably save $1.5 - $2 million a year.” David Beech, Watson Wyatt Benefits Consulting

• Workplace Health & Safety (McCaskal, et al, April 2014, 62 no. 4, 152-169)-– reports that an alternative to combat the rising health care costs

without reducing the number of employees or compromising the access to quality health care is offering an on-site health clinic to employees

Benefits of on-site clinic as compared to services provided under our medical plan:

HEALTHY WAY CLINIC MEDICAL PLAN• No deductible to meet • $3,000/$6,000 minimum deductible

• Fee schedule same or lower  • Office visit copays are subject to deductible

• Expenses are eligible for HSA reimbursement • Expenses are eligible for HSA payment or reimbursement

• Expenses are NOT eligible for HRA reimbursement • Expenses that exceed deductible are eligible for HRA reimbursement 

• CONVENIENCE!  ACCESSIBLE! • Access to provider may be delayed

• Reduction in time away from work 

Expenses incurred at Healthy Way Clinic are not submitted to our medical plan!

Planning

• On hire-June 2013 told of vision driven by our CEO

• Developed an initial plan to learn more– This included data gathering and visiting other Children’s with on

site clinics– Created a survey to be used when visiting other sites– Jan-Mar 2014 visit other sites(Instead of going to Global Media Dynamics seminar put on nationally that focused on onsite employee health clinics)

• Data Reviewed and shared with senior leaders-”GO”

Planning

• July 2014 came together and began to formulate the plan

• August 2014 timeline developed & first stakeholder meetings held

• October 2014 shared final plan with Leaders

Timeline

Grand Opening January 5, 2015

Stakeholder Meetings

• Began in August 2014• Had to determine who to bring to the table• Determined-

– Lab– Pharmacy– Radiology and Radiologist Group– Facilities– Leaders– Local Occ Med Company to offer the providers– Broker, Attorney et al.

Outsource?

• Costs much greater for us• Have a solid Employee Health Clinic already• More control if we run it

• So decided not to…..

Care Model

• Looked at models of care provided by mini clinics in local stores (i.e., Kroger, Walgreens, etc).

• Determined we wanted to offer this type of minorinjury/illness care--- “Urgent Care”.

• Not Primary Care or care for chronic conditions

The clinic cannot provide services for:

• Anyone younger than 18-years-old• Conditions that require FMLA paperwork (e.g.,

pregnancy, chronic health conditions)• Obstetric or gynecologic conditions• Chronic disease management: (cardiovascular disease,

diabetes, hypertension, etc.)• Severe chest pain• Severe bleeding• Severe shortness of breath or difficulty breathing• Suspected poisoning• Adults with a temperature higher than 103F• Conditions that require our practitioners to prescribe

controlled substances• Mental health conditions (The center will refer to the

Employee Assistance Program)

New Services Mid Year

• Employees can meet with a Dietitian-Free • Employees (spouses) can meet with Lactation

Consultant-Free

• Considering-– Immunizations for spouses– Care for adult child-22-26 years

Staffing

• 1.0 Clerical --Front Desk and Phone

• 1.5 RN

• Contract NP -16 hours a week

• Contract MD - 4 hours a week

• PRN use contracted MA or LPN

Provider Contract

Hourly Rate

FlexibilityWC

Coverage

Liability

Experience

Relationship

IndemnityMed

Malpractice

Start Up Funding

• Proposed funding

– FY14 health insurance account savings• As of 4/30/14 reflected (623,317)

– Reduction in overall claims• 2-4% savings reported by CHA hospitals

Start Up Costs

• Free Space-due to move to new site

• Small Renovations– Went from 2 exam rooms to 4– Created Medication Room– Drug Testing Bathroom– Private Nursing Station/area—walk way– Changed the reception area

• Free Equipment

Start up Costs

COST ITEM $  2,200.35 Marketing, Mailing, Atty$  1,318.90 Misc Supplies; Atty$40,856.00 Renovation$  1,354.25 Atty $      518.92 Stress Balls$  4,370.00 Capital Equipment $50,618.42 TOTAL 

Equipment

• What did we need for rooms?– Created lists of items (chairs, stools, etc)– Shared with facilities

• What did we need to provide the care?

• What would the costs be?

• Medical Records

Form Development

• No EMR to start• Consent to Treat form• Patient Summary form• Patient Intake form• Discharge instructions• Billing sheet• Consent to Care for Spouse and Spouse billing sheet• Biometric Results Form• New Sign-in Sheet• AMA sheet

Fees

• Discussed “what is considered deep discount”• How will the patient pay?

– Paper payroll deduct form– No cash or cards– No H.S.A. cards…

• How will the spouses pay?• How do we determine the Cobra rate since this is Cobra

eligible?...

HSA Reimbursement

• Employees can reimburse themselves for expenses by choosing themself as the payee and the bank will send a check for the amount requested and then debit the account for that amount free of charge. The employee will receive a check in the mail in just a few days.

Fee Structure

Deeper Dive

HIPAA

Deep Dive

• Would we complete FMLA Paperwork? NO• Are there ADA concerns? NO• Stark Law-Cannot treat referring/community Drs• COBRA eligible? YES• ERISA-Need to add items to benefits plan document• Need a patient rights document to be offered • Add amendment to the contract with the provider-spouses• HIPAA-need to allay concerns of employees

ERISA

• Employee Retirement Income Security Act of 1974

• When offering on-site clinic that provides care beyond first aid and treatment of minor injuries should incorporate such clinics into their existing group health plan document, adopt a wrap plan document, or create separate documentation to ensure that ERISA and Department of Labor regulatory compliance requirements are met

https://complianceadministrators.com/on-site-health-clinics/

COBRA

• Allows for employees to maintain insurance coverage when not active an employee

• Can be costly to former employee• Is your clinic COBRA eligible?

– If provide medical care beyond first-aid and minor injuries must offer COBRA continuation coverage to all eligible employees upon the occurrence of a COBRA qualifying event. If an employee’s spouse and dependents have access to the on-site clinic, they would also have COBRA rights.

– Must receive a COBRA notice

https://complianceadministrators.com/on-site-health-clinics/

COBRA Rate

To determine rate --• Take operating budget and divide by # eligible

employees then divide by 12 for monthly rate.

• $500,000 (our budget #) / 1999 (all employees eligible) / 12= 21.00

• Decided to go with 40.00 monthly cobra fee to cover more of the visit costs. Added to our notices.

FMLA

• We needed to determine how we would handle this if requests came in

• Our answer was NO-we would not get involved with FMLA or providing Medical Coverage or Certifications

• We do not care for “chronic” or qualifying events.

The Joint Commission(TJC)

• Being in a Hospital had to take this into account

• Did we meet all of their requirements– Medications– POCT– Patient Summary– Patient Rights and Responsibilities

STRONGLY Recommend

• Bring in Benefits Experts

• Bring in Attorney-sooner the better– Help with contract– Guidance with all related laws and requirements– Consents– Etc, etc…

By the Way….

• Biometrics!– Need a process for this; – What will we test; – Forms– Onsite or offsite-proposals– Our Lab on board

• Spouses—work to do! Definition

• Are meds really free? Oops!

Medication Offering Change

• Needed to stop the FREE meds

• Reviewed what was filled here and charged for – Jan-May 2015 filled 245 meds for fee of 4817.54– Only about 20.00/script

• Possibly improved compliance in getting the med

• Again ease of access (right here)

Other items

• Patient Satisfaction Card

• Patient Satisfaction Tally Report

• Volume Count Report

• Marketing Brochure

• Marketing Posters

• Our Name…

Marketing & Communication

• Began talking about the clinic at benefits fairs in the fall of 2014.

• Completed a video-Early December 2014• Created posters for ALL units and hand delivered• Brochures about the clinic mailed to homes• Purchased stress balls to give out in the cafeteria• Article on the Intranet• FAQ on the Intranet and own page• Shared details at “Town Hall” type meetings for all

Key to Marketing

• Hit employees through multiple methods

– Email– Intranet– Video– Mailings to home– Talked at House-wide Meetings– Posters

Our Brochure

Marketing Video

• https://www.youtube.com/watch?v=wArm7VC1tvM&feature=youtu.be

• Close to 700 hits on our intranet

FINALLY!

• The Ribbon Cutting Event !!

Sustainability

• When employees have a positive experience, get good care and the clinic is providing proven value to the employer it will continue well into the future.

• To be sustainable must address economic efficiency, social equity and environmental accountability.

Workplace Health & Safety (McCaskal, et al, April 2014, 62 no. 4, 152-169)

Goals

• Reduction in medical plan spend

• Integrated occupational health and employee/spouse health model

• Establish pathways to establish primary care physician relationship

• Create linkage to specialty physicians

• High employee satisfaction

Measure of Success

• ROI-if able to capture-basically $ in vs. $ out• Cost Benefit Study• VOI• Improved Employee Engagement and Satisfaction• Improved Productivity--??Measure??• Reduce out of pocket expense for employees• Reduce Time Away from Work• Reduce Claims and Claims Costs• Positive volume growth• Positive word of mouth

Planned Measures• Two year pilot program:

– 800 added visits in year one-• 2015 ended at 664• Claims reduction of *$67 each = $53,600

– 1200 added visits in year two-• 2016 ytd July 1 at 489• Claims reduction of *$67 each = $80,400

– 1% reduction in overall claims expense at end of year two• Approximately $120,000 (not measured yet)

– Employee satisfaction score of 4.0 or higher on scale of 1.0-5.0• 4.78 average in 2015• 4.88 first quarter 2016

* $67.00 ave office visit fee

What are we Capturing?

• Patient Satisfaction• Employee Engagement• Patient Volumes• Costs• Which Depts are utilizing• What types of visits we are seeing• Claims Data baseline and current to compare

FY 15 Year End Budget

• Our Fiscal ends July; July 2015 we were open 6 months• Our first year loss of $293,124 far offset our health

benefits savings for the year which was $1.3 million

Actual Budget VarianceContract (Old line item) $59,548.00 $186,791.00 $127,243.00Med Evals $16,082.00 $7,510.00 ($8,572.00)Lab $57,941.00 $8,244.00 ($49,697.00)Drugs $54,667.00 $56,889.00 $2,222.00Supplies $372.00 $513.00 $141.00HW Clinic $364,461.00 $0.00 ($364,461.00)Total $553,071.00 $259,947.00 ($293,124.00)

Budget FY 15

Volumes with Visit Type

What are we seeing?

• Flu• UTI• Rashes• Colds/Sinus• Ear irrigations• Physicals for school• Home injuries• Over 900 Biometrics• More Work Injuries treated here

Patient Satisfaction Cards

Process Improvement

• Recently (end of 2015) began sending the cards out electronically as we noticed a decline in the return rate via mail.

• Much higher and more timely return rate since.

Patient Satisfaction Tally

Question 1 2 3 4 5 Average Score

1. Ease of making appointment 0 0 0 1 24 4.96

2. Ease of registration process 0 0 0 0 25 5.00

3. Wait to be seen 0 0 3 1 21 4.72

4. Courtesy and friendliness of staff 0 0 0 0 25 5.00

5. Quality of care received 0 1 1 2 21 4.72

TOTAL 0 1 4 4 116 4.88

NumberMailed Out 57Returned 25 6/8/2015Total Possible if all 5 125Total Score as a percent 92.80%

Comments/Suggestions for improvement:

Survey Results May 2015(1= very dissatisfied 2=dissatisfied 3= neutral 4=satisfied 5=very satisfied)

What are Employees Telling Us?

Give out suckers

Excellent customer 

services and service the hospital provides 

Thank you for your amazing 

service!! 

Great care right here at work! I am recommending the clinic to everyone! 

Really nice to have this available to employees and 

their families. Very positive. 

Prompt. Nice option when I 

work

1st time using clinic. Waited 30+ minutes to be seen by CNP, eventually had to leave 

and reschedule appointment. 

I'd like to schedule online instead of making 

a phone call. 

Share The Data

• Each month our volumes and patient satisfactions get shared-– With my boss-Director of HR– With my boss’s boss-Chief Operating Officer

• This can generate questions such as are you seeing trends?

• Need to be ready to extrapolate data and explain it

Lessons Learned

• Talk to others and review the data• Seek assistance from Legal, Benefits• Get SL support• Stakeholders on board• Plan, Plan, Plan• Be Flexible• Give yourself enough time• Marketing is key• What other services can be provided

What is Your Elevator Speech?

• If you are asked about your program, how will you respond?

• Tell your story.• Be prepared--Know your numbers• Be ready to share “on the fly”………..