The following three onsite delivery models were presented at RYAN Associates’ seminar on Profiting from Product Line Diversity and will be featured during a summer webinar series. The series, scheduled on consecutive Wednesdays July 27 through Aug. 24, is sponsored by RYAN Associates in conjunction with the American Association of Occupational Health Nurses. (Please refer to Page 18 for details.)
Nurse Practitioner Clinics Denia Lash, Director, Business Health Services Blount Memorial Hospital, Maryville, Tenn.
Business Health Services adopted a nurse practitioner-centered clinical delivery model in the mid-1990s in response to customer requests for the provision of personal health care services at the worksite.
“The first thing you to have to determine is who you are going to be taking care of in the nurse practitioner clinic,” Ms. Lash said.
“Different companies take different approaches, and it all relates back to your cost savings and value to the company.”
For example, will the clinic be exclusively for employees or will adult dependents also be treated there? What about retirees and/or children? Will the clinic provide personal health care, immediate care, occupational medicine, or a combination of these services?
Business Health Services’ nurse practitioners see children no younger than 6 years old and refer them to a pediatrician for follow-up. Local pediatricians felt that treating children under 6 in an onsite clinic could potentially compromise their ability to ensure their youngest patients receive all of their immunizations on schedule before enrolling in school.
Meanwhile, early retirement options that feature employer-provided health care as an added inducement to retire have prompted an increased demand. “That has been a huge benefit for some companies,” Ms. Lash said.
She also noted that employers like to have a nurse practitioner onsite because they can write prescriptions and dispense medications. “It is cost-effective for the company,” she said. “Some companies will fully cover medications as a benefit for their employees and charge a modest flat fee for dependents. Many also provide lab work at no cost to dependents and employees.”
In another recent development, she said Business Health Services has placed a nurse practitioner at one of its clinics to work with an employer with a dispersed workforce and multiple locations. The company pays an hourly rate for the nurse practitioner and is her sole client. When the nurse practitioner is not occupied with employees from the company, she works in the clinic with the general patient population.
Ms. Lash said the program also uses health risk assessments and educational programs to help facilitate a customized approach at the workplace. BHS employs a registered nurse-health coach who provides onsite wellness programs such as organized walking, nutrition classes, and smoking cessation. In addition, focused disease management activities are overseen by onsite clinical personnel. For example, at one company the onsite nurse practitioner introduced a comprehensive diabetes management program when data showed 45 percent of the company’s healthcare claims were associated with 250 diabetic employees in a workforce of 2,000. In such cases, actual cost savings over time are measurable.
When providing onsite services, it is essential to demonstrate the program’s value to both the client company and your parent organization, said Ms. Lash, whose program has offered a clinical personnel placement program for 25 years. It started with one nurse and has since expanded to 46 nurses, nine nurse practitioners, as well as physicians and physical and occupational therapists who work onsite as needed to address job-related medical and surveillance issues.
“I cannot stress enough the importance of having objective data to show your value,” Ms. Lash said. “We had a client company representative who said, ‘We really don’t care if you save us money. This is the right thing to do.’ We knew it was the right thing to do. We also knew we needed to monitor performance.
“Wouldn’t you know it? That person left the company, and the first thing her replacement asked was, ‘Where you have saved us money?’ It was a no-brainer because we had been tracking ROI all along. But if we had needed to start from scratch, it would have been very hard to demonstrate our value.”
In another case, the hospital and its board of directors were questioning the value of an onsite contract that appeared to result in an annual net loss of more than $255,000. (Table 1, Company 3). However, when referral revenue was taken into consideration, it came to light that Company 3 had generated nearly $900,000 in annual net income for the health system. Business Health Services gets credit for half of that amount based on an assumption that about half of all cases would have ended up at Blount Memorial Hospital regardless of a BHS relationship.
“Interfacing with your parent organization is where the rubber meets the road,” Ms. Lash concluded. “Great that you are offering these wonderful services, but you have to be able to show what it means for your organization.”
Mobile Nurse On-Call Injury Care Greg McQueary, Director, Outreach and Occupational Health Centers Beloit Memorial Hospital, Beloit, Wis.
Not to intentionally digress, but did you know the cheese curl was invented in Beloit, home to such snack food giants as Frito Lay, Kettle Chips, Diamond Nuts, and Hormel?
Put that together with the fact that even in a recession people still get the munchies and you will understand how Beloit Memorial Hospital has been able to successfully sustain its occupational health operations.
Another key to the program’s long-term success is a unique service in which nurses respond to calls for injury care at the worksite. According to Mr. McQueary, here is how it works:
- An employee is injured on the job. A supervisor or first responder calls the occupational health center. A nurse takes the call and provides phone triage to ascertain the nature and extent of the injury. If it is not a 911 emergency, the nurse provides immediate first aid advice and her estimated time of arrival at the worksite. The travel range is generally within a 15-mile radius of the clinic.
- The nurse drives to the company in a van, one of two owned by the health system for that purpose. She carries a cell phone, a trauma bag, and other supplies in the vehicle including urine drug screening kits, splints, and a Wood’s lamp. “This is an emergent care program. We do not have flashing lights; this is a nurse in a van,” Mr. McQueary said. “We always make that clear to employers when we do orientation.”
- The nurse evaluates and treats the patient in accordance with physician protocols based on American College of Occupational and Environmental Medicine guidelines. The Wisconsin Nurse Practice Act allows a registered nurse working under the general supervision of a physician to provide care while following a decision tree.
- The nurse completes an injury assessment form with work restrictions if needed, and a recommended date for return to full duty. The nurse gives the information directly to a designated contact person at the worksite.
- If the patient requires immediate physician follow-up and/or X-rays (and if it is not an emergency), the nurse transports him or her to the occupational medicine center. In such cases, any liability rests with the health system, not the employer.
- The client company, not the workers’ compensation insurance carrier, is billed for minor injury care based on treatment time and applicable ICD-10 codes. Average fees range from $55 to $120 per visit. There is no additional charge for the nurse to come onsite.
- “This has helped keep fees down and allows the client to determine which bills are sent to the carrier,” Mr. McQueary said. When the nurses are not out on a call, they work in the clinic. On a typical day, one nurse works full-time in the clinic and a second nurse is on call, ensuring consistent coverage. “We also have some educators on staff, so generally speaking we have extra people who can assist when we get really busy,” Mr. McQueary explained. According to Mr. McQueary, in 24 years, 70 percent of the injured workers seen onsite by the nurse have been returned to full or modified duty following treatment; 23 percent have been referred to a physician for follow-up. About a third of those in need of additional care have been transferred to immediate or emergency care, depending on the situation. Less than half a percent have asked to see their own physician for follow-up.
The onsite mobile injury care services benefit employers by:
- Relieving supervisors of care assessment responsibilities;
- Allowing managers to stay at work rather than accompany an injured employee to a clinic or emergency room;
- Supplying them with immediate information about the injury, treatment, and restrictions;
- Providing affordable, convenient, quality care;
- Providing access to a “company nurse” on an as-needed basis.
Advantages to the health system include:
- A chance to build goodwill;
- Opportunities to “get in the door” and/or cross-sell services at more companies;
- Visibility, i.e., “traveling billboards” on the side of vans;
- Ability to help employers manage OSHA recordable and workers’ compensation injury incident rates;
- Being viewed as a problem-solver and consultant to industry.
“We believe this is an innovative approach,” Mr. McQueary said. “It is a value-added service. Our hospital was not very well perceived in the business community when we started this in 1987. Now they love us. We are a not-for-profit organization, so a positive relationship with business and industry has other huge ramifications in terms of their support.”
Onsite Employee Clinic: 10 Ways to Avoid Pitfalls Lorraine Chambers Lewis, P.A., Corporate Director, Employee Health Services North Shore-Long Island Jewish Health System, New Hyde Park, NY
The North Shore-Long Island Jewish Health System is certainly no small fry. It includes 15 hospitals and has more than 42,000 employees, making it the largest employer on Long Island and the ninth largest in New York City. Its service area encompasses Long Island, Manhattan, Queens, and Staten Island, with a population of about 7 million people.
Despite its size and depth of resources, it was still necessary to go through a learning curve in response to a request from a local employer to establish an onsite medical clinic. Ms. Chambers Lewis cited the following lessons from the experience:
Embrace a vendor mentality.
Assign a project manager who will be responsible for assembling information and meeting deadlines. The health system is the vendor and therefore the primary contact and responsible party, regardless of any other third-party experts who may be involved. Lack of control as the vendor can result in communication lapses and inconsistencies, and may project a poor image. Clinic development should appear seamless to the client.
Adopt a realistic implementation timeline.
There are many aspects to opening an onsite clinic, some of which occur simultaneously and all of which require planning. “If you do not communicate the timeline with the client, they will fill in the blanks themselves,” Ms. Chambers Lewis cautioned. Components to take into consideration include, but certainly are not limited to:
- Executing the service agreement;
- Setting up service contracts for third-party entities;
- Recruiting, training, and credentialing staff;
- Selecting and implementing an information management system;
- Ordering equipment and supplies, including working with your organization to develop a supply chain that can reasonably accommodate lower-volume ordering;
- Establishing a legal entity and executing legal documents;
- Establishing a cost center and being prepared to demonstrate ROI;
- Developing a marketing strategy and related materials;
- Obtaining a Department of Health certificate.
Outline space requirements.
Refer to best practices in Guidelines for Design and Construction of Health Care Facilities (https://shop.fgiguidelines.org/). The Joint Commission, many federal agencies and state authorities use the Guidelines either as a code or a reference standard. “Remember, you are going into someone else’s house. They are very proud of their house, and they don’t like to be told what to do in it,” Ms. Chambers Lewis said. “They have their own architect. They have their own contractors. The client may say, ‘You don’t have to tell me what to do to build a healthcare space,’ but you are the one who has to meet certain standards. There are best practices for medical reasons with which the client may not be familiar. You have to communicate that from the beginning. Last minute revisions can be quite costly.”
Define the scope of services.
Develop a list of services and the corresponding business value to the client. Do not overpromise nor limit the opportunity to develop wellness/disease management interventions.
Identify staffing needs.
The desired scope of services dictates the type and level of staffing you will need in the onsite clinic. Whether on or offsite, a medical director who is comfortable with the scope of practice must provide oversight. Begin recruitment as early as possible and allow time for credentialing and orientation processes. Consider each applicant’s ability to engage the client, the workforce and the individual patient. Orient all staff on customer/patient service practices.
Establish a fee structure.
A flat monthly fee is preferable for the delivery of routine services. Otherwise, there can be unexpected fluctuations in revenue and a greater risk for errors in invoicing. Promote your organization as “dedicated to servicing the workforce regardless of utilization.” On the other hand, to avoid over-or under-budgeting, it is advisable to invoice a client based on utilization when more costly, variable services are involved. Examples of such variable costs include some vaccinations, lab tests, ergonomic evaluations, biometric screening and wellness presentations.
Create an electronic operations manual.
The manual should contain protocols and policies for all aspects of onsite clinic operations. Examples include protocols to ensure regulatory compliance (e.g., bloodborne pathogens, handling bio-hazardous materials); medical practice guidelines; staff competencies; patient privacy requirements; communication and reporting practices; and medication storage.
Agree on hours of operation.
Some aspects to consider: staff to arrive 30 minutes before the clinic opens; scheduling the last patient 30 minutes before closing; encouraging late walk-ins to schedule an appointment for the next day unless it is urgent.
Promote the clinic.
Develop a marketing plan. Use multiple channels of communication such as brochures, email, posters, display tables, mailings, card tents and orientation talks. Marketing should be ongoing, not just a launch event. Give the clients latitude in the range and cost of marketing strategies.
Measure performance.
Establish a medical record quality review process for clinicians. Create performance metrics, score-cards and a dashboard for the client company to review. Emphasize metrics that are most relevant to the company and make them “simple and attainable,” Ms. Chambers Lewis said. Examples of areas to measure include overall employee utilization of the onsite clinic; requested services; patient satisfaction; top three diagnoses; and volume of newly diagnosed chronic conditions.
