Innovative Models of Care - Walgreens Healthcare Clinics

Innovative Models of Care
Walgreens Healthcare Clinics
Sandra Ryan, Chief NP Officer and Clinical
Advocate Take Care Health Systems
©2013 Walgreen Co. All rights reserved.

Agenda
• Overview of Walgreens as a Health and Daily Living
Destination
• Evolution of the Convenient Care Industry/Retail Clinics
• Role of Convenient Care and the NP in the Retail Clinic
• Overview of the Role of NP Leadership
• Future Role of the Nurse Practitioners in Healthcare

•Walgreens Well Experience:
•Transforming the traditional drugstore to a health and daily
living destination
•Vision: To be for everyone in America – the first choice for
health and daily living, owning the strategic territory of ―well.‖

Walgreens Plays a Critical Wellness Role in
Communities Across the Country
• With more than 8,500 multichannel points of
care, Walgreens gives you the power of a national
footprint with the reassurance of a personalized
local presence
• Walgreens is the largest national provider of
immunizations, second only to the US government
• Walgreens is the largest pharmacy retailer in the
country, filling more than 21% of all scripts – more
than any other pharmacy network
• 6.1 million customers visit Walgreens everyday
• Over 800 Clinics, in retail health outlets and
worksite-based health and wellness centers, many
in ―med-deserts‖
©2013 Walgreen Co. All rights reserved.4

Walgreens Healthcare Patient Touchpoints
 180 Hospital Outpatient Pharmacies in major institutions such as Yale and
Northwestern
 WellTransitionsTM discharge solution significantly reduces hospital readmissions
Hospital System
Solutions
National Network
of Retail
Pharmacies
8,200+ pharmacies employing 70,000+ trusted health care professionals
 Located within 3 miles of ~65% of Americans = 6 M customers each day
Specialty
Pharmacy
 #4 in the Industry-17 integrated Specialty Health Programs
 700 HIV Centers of Excellence
Infusion Services
 #1 infusion provider with 75 Rx & 100 Alternate Treatment Sites in 36 states
 1,400 nurses deliver infusions either at home or at our sites
Retail Clinics
Employer Health
Centers
 375 On-site health centers at employer locations; 40+ years experience
 160+ employer clients in 45 states; serving ~10 M employees at work
 400 Healthcare Health Clinics located in Walgreens stores in 19 states + DC
 1,500 NPs and 40 PAs; every clinic has a collaborating physician
 Chronic and Acute disease management programs
• 5
©2013 Walgreen Co. All rights reserved. Confidential and proprietary; should not be
re-produced or re-distributed.
•DRAFT- ACCOUNTABLE CARE SERVICES

©2013 Walgreen Co. All rights reserved. 6
Retail Industry-Healthcare Clinics

The Problem-A Broken Healthcare System
Primary Care — Will It Survive?
Thomas Bodenheimer, M.D.
•“Family Medicine cannot fully succeed, nor will the needs
of the public be met, without fundamental changes in the
U.S. health care system.”

Facts
 50 million Americans are uninsured, including 1 in every 8
children. (Census Bureau, 2010)
 70% of Americans report they can’t get same-day
appointments with their PCP. (Commonwealth Fund 2007)
 29% of Medicare recipients (11.6 million people) have a hard
time finding a PCP who accepts their insurance.
(Commonwealth Fund 2007)
 30% of Americans lack a regular source of primary care.
(Commonwealth Fund 2009)
 Almost half of all emergency room visits were non-emergent in
nature or otherwise treatable in primary care settings.
(Desypher Analytical Services, 2010)

Healthcare Access is in Crisis
9©2013 Walgreen Co. All rights reserved.
• Limited access to routine and
preventive care.
• Millions of consumers do not have an
established physician relationship or
health insurance.
• Health care costs are rising at
unsustainable rates. Healthcare cost
estimated to be 20+% of the GDP by
2020.
• Consumers are demanding
convenience.
• These issues will worsen as the
primary care shortage grows.

Disrupting the Traditional Model
Convenient Care/
Retail Care has been
termed a ―disruptive
innovation.‖

More than 390 Locations in 34 Markets, 21 States
-
• Atlanta
• Boulder
• Chicago
• Cincinnati
• Cleveland
• Colorado Springs
• Columbus
• Denver
• Ft Lauderdale
• Houston
• Indianapolis
• Jacksonville
• Kansas City
• Knoxville
• Las Vegas
• Memphis
• Miami
• Milwaukee
• Nashville
• New Orleans
• New York City
• Orlando
• Philadelphia
• Phoenix
• Pittsburgh
• St. Louis
• Tampa
• Topeka
• Tucson
• Washington DC

Industry Growth
12
• Growth in the number of clinics is anticipated in the coming years
(Deloitte Center for Health Solutions, 2009)
• Scope of services is being expanded with an eye towards disease
prevention and chronic disease monitoring and management.
• More hospitals and health systems now operate clinics than non-
hospital companies, though the majority of individual clinics are still
operated by non-hospital companies.
• Growth among hospitals is largely due to perceived benefits of the
relationship in supplementing and extending existing care
(RAND, 2010).

Personalized Quality Healthcare Made Easy
 High-Quality
• Evidence-based
• Nurse Practitioners
• Streamlined technology, E-prescribing
capabilities, transparency of quality
metrics
 Convenient
• No appointment needed but can schedule
one
• Open 7 days a week – evening, weekend,
and holiday hours
 Affordable
• Lower-cost access to care
• Most major insurance plans accepted
• Transparent Pricing

Delivering a Patient Centric Experience
14
• 260+ square feet
• Two exam rooms, with exam
tables
• Restroom facilities nearby
• Most clinics conveniently located
across from the pharmacy
• Professionally outfitted with state-of-
the-art
technology and medical equipment
• Electronic sign-in kiosks/LCD
• Patient queue, with wait time visibility
• Electronic Health Records

Growing Range of Services
Examples
• Flu shots
• Hepatitis A & B
• Meningitis
• MMR (Measles, Mumps, Rubella)
• Tdap (Tetanus, Diphtheria, Pertussis)
• Varicella (Chicken Pox)
• Zostavax (Shingles)
• Physicals (camp and sport)
• Health screenings HRA’s
• Medicare Wellness Exams
Examples
• High Blood Pressure
• Specialty Injection Services
• Asthma
• Cardiovascular conditions
• Chronic bronchitis
• Diabetes
• High Cholesterol
• Osteoporosis
Examples
• Strep throat
• Sinus infection
• Bronchitis
• Ear infections
• Urinary tract infections
• Seasonal allergies
• Minor burns
• Sprains/strains
• Skin rashes
• Cold and mouth sores
• Tick/insect bites and stings
• Wart removal

Exceptional Patient Experience
•ACCESS
•TRANSPARENCY
 Wait times, patient satisfaction, and quality metrics
transparency via Walgreens.com to guide patient choice
 Cash prices, as well as insurance plans accepted, available via
in-clinic signage and website
- Most insurance plans accepted, including Medicaid
- Affordable costs for cash paying patients
• Clinics can serve as a cost-effective alternative for
overflow, after hours, and non-emergent needs
• Open 7 days a week, including weeknights
• Walk-ins welcome and appointments available

Exceptional Patient Experience
•SIMPLICITY
•PATIENT
SATISFACTION
• A simple, paperless check-in process and clear information about
estimated wait time
• E-prescribing to allow access to patients’ pharmacy of choice
• On line and in clinic appointment scheduling available for patients
• Patient satisfaction is in the top 10% of Gallup Consulting’s
consumer database
• Follow-up phone call within 48 hours of their visit
• Health Care Clinic strongly engages more than three out of every
four patients, while the typical company that works with Gallup
strongly engages fewer than one in four of their patients
• More than 95% of patients agree that ―the Nurse
Practitioner/Physician Assistant spent enough time with me‖ and
―health matters were explained in a way that was easy to
understand “

Clinical Excellence
•BEST-IN-
CLASS
•PROCESSES
•WELL-
TRAINED
•CLINICAL
STAFF
• Use of evidence-based frameworks and expert review of clinical policies
• Quality benchmarked against national standards, such as HEDIS
• Clinic exceeds national HEDIS benchmarks in measured categories
• Chart review process, facilitated by EMR, includes both peer review and
Collaborating Physician review
• Clinicians credentialed in accordance with NCQA guidelines
• Enhanced certification and education of our clinicians
• Accreditation Association for Ambulatory Health Care (AAAHC) accredited
EVIDENCE-
BASED
RESOURCES
 American Academy of Pediatrics. Pediatric
Clinical Practice Guidelines & Policies (2012)
 Red Book Online American Academy of
Pediatrics (2012)
 Harriet Lane Handbook (2012) Pediatric Book
 DynaMed Online (2012)
 Veterans Affair/DoD Clinical Practice Guidelines
Online
 Epidemiology & Prevention of Vaccine-
Preventable Diseases, CDC (2012)
 Sanford Guide to Antimicrobial Therapy
(2013) Antimicrobial Therapy Incorporated
 Griffith’s Education for Patients (8th
Edition, 2011)
 Skin Disease: Diagnosis and Treatment by
T. Habif (2011)
 Epocrates Interactive Online Premium
(2012)
 Cash, J.C., & Glass, C.A., Family Practice
Guidelines, Second Edition
 Yellow Book For Travel Vaccines, CDC,
2012

• 13.7-27.1% of
all ED visits
could take
place at
alternative
sites.
• Potential $4.4
billion in
annual cost
savings.
An Alternative to the ED

Improving Access
As many as 40% of clinic patients report not having a PCP
(Mehrotra et al. 2011)
Some hospital systems report their retail clinics are the largest
entry point into their healthcare system. (Mehrotra et al. 2011)
~12 to 14% of all ED visits can be seen at convenient care
clinics (Weinick et al. 2010; Mehrotra et al. 2008).
93% of patients report highly on the convenience (Wall Street
Journal/Harris Interactive 2008).
Nearly 30% of the U.S. population lives within a ten-minute
drive of a clinic (Rudavsky et al. 2008).

Decreasing Costs
• Retail clinics reduced ER use and costs for pediatric
population, and reduced admissions and outpatient costs for
patients with chronic illnesses (Parente n.d.)
• Costs of care at a convenient care clinic are significantly
lower than those at an urgent care center, primary care office,
or emergency department (Mehrotra et al. 2009; Thygeson et
al. 2008).
• Blue Cross and Blue Shield of Minnesota eliminated co-pays
for enrollees who used a clinic, citing $1.2 million in cost
savings (Minneapolis/St. Paul Business Journal 2008).
• Retail clinics have a return visit rate comparable with
standard medical offices - care is high quality and does not
generate additional follow up utilization. (Rohner et al. 2012)

Peer Reviewed Quality Outcomes
Convenient care clinic providers adhere to evidence-based
practice guidelines and exceed national benchmarks
(Jacoby et al. 2010; Woodburn et al. 2007).
Quality scores and rates of preventive care offered are
similar for convenient care clinics as for other delivery
settings (Mehrotra et al. 2009).
• Convenient care clinics had a 92.72% compliance with
quality measure for appropriate testing of children with
pharyngitis vs HEDIS average of 74.7%; they also had an
88.35% compliance score for appropriate testing of
children with URI vs HEDIS average of 83.5%. (Jacoby et
al. 2010)

Role of Nursing in Retail Industry

Chief Nurse Practitioner Officer
 Roots in military corps concept: Nursing is its own profession
 1st in Retail Clinic industry
Executive voice of the NP—First NP leadership track in industry:
• Clinical and Business leaders
- Design work-environment to meet patient and provider needs
- Develop proprietary EMR made for NPs
- Create shared governance model from the start
- Emphasis on quality
- Nursing leadership development
 Challenges:
• Bridging gap between clinical and business
• Regulatory constraints

Visibility For NP’s
National representative of NPs for CCA
• Creation of Quality and Safety Standards and Recommended Practices
• Implementation of independent certification program for CCA members
• Legislative representation to address role of NPs in retail model nationally
• Gaining visibility in the media and among third-party researchers as a valuable
source
• Founding National Convenient Care Clinic Week; integrating convenient care
into the national dialogue about healthcare and healthcare reform
• Launching the CCA Clinician Portal to support and engage clinic providers
• Establishing partnerships with major national publications;
• Standardization of image of NPs in the retail industry
Robert Wood Johnson Executive Nurse Fellowship
Fellow of the College of Physicians Philadelphia

Future of Retail and Nursing

We have the wind beneath our feet !!
Affordable Care Act
• In March 2010, President Obama signed the Patient
Protection and Affordable Care Act (ACA), into law.
The law makes preventive care accessible and
affordable for many Americans. While some
provisions of the law have already taken effect, many
more provisions will be implemented in the coming
years.
• Enrollment begins October 1, 2013 for coverage
beginning January 1, 2014 (U.S. Department of
Health and Human Services).

Report Recommendations:
Nurses should practice to the full
extent of their education and training
Services offered at retail clinics allows for
nurses to practice to the fullest extent of
their education and training within a retail
setting.
 Acute care
 Preventive & wellness care
 Chronic disease diagnosis &
management
•The Future of Nursing- IOM

National Governors Report
30
The Role of Nurse Practitioners in Meeting Increasing Demand for
Primary Care
December 20, 2012
States could increase access to primary care for their residents by consider
easing their scope of practice restrictions and modifying their
reimbursement policies to increase the role of nurse practitioners in
providing primary care
Reviews academic and policy-oriented literature and state rules governing
nurse practitioners’ scope of practice to examine the extent to which:
• Scope of practice rules, licensure and other conditional requirements
vary across states;
• States’ rules and requirements deviate from evidence-based research of
appropriate activities for nurse practitioners; and
• Changes to state scope of practice laws and regulations affect access to
health care and its quality.

Current Legislative Environment:
What it means to the NP Role
 Need for increased access: 30 +million more insured lives
• Innovative models to address Physician shortage
- More Nurse-Managed Healthcare Centers
- Innovative models with all electronic, interoperable processes
 NPs are positioned to educate and implement wellness and preventive
medicine – holistic care
 Quality: Accountable Care organizations (ACO’s)
• Rewards provider-led organizations that take responsibility for the costs
and quality of care received by their patients over time.
• Will see increased partnering between health groups, including
collaboration with NPs
 Retail clinics engage in creative partnerships (employers, community health
centers, private sector, payors
 Federal Funding: Nursing education grants and loan programs to strengthen
nurse training programs GNE

Future is BRIGHT for Patients and NP’s
32
Bracing for Obamacare: Nurse practitioners fill doc shortage gap
Aug. 9, 2013
This is the first story in NBC's series "Quest for Care" exploring the shortage
of health care providers as the Affordable Care Act rolls out.
August 14, 2013
Nurse Practitioners Seek Right To Treat Patients on Their Own
Health Professionals in Five States Fight to Shed Doctors' Oversight

Change is the Future…our Role
From fee for service to value based programs, from face to face and the
potential for telemedicine, from independent primary care practices to
systems and from encounter based medicine to person based health.
We need to:
• Use Health Information to manage and coordinate care
• Utilize all health professionals to their fullest extent
• Collaborate to integrate services
• Help other to Navigate the Change-Stay Patient Centerd
• Strive for Healthy communities
• Look to innovate to accelerate the pace of change
Tipple Aim Better Care, Better Health, Lower Cost
It’s time to look beyond the past, think about the present and be
about the future
•*Photo courtesy of Keith Green DDS Family Dentistry

The FUTURE
34
― Our deepest fear is not that we are inadequate. Our
deepest fear is that we are powerful beyond measure…” It
is our light not our darkness that most frightens us..as we let
our own light shine we unconsciously give other people
permission to do the same.‖
Nelson Mandela

The END
THE BEGINNING!
Sandra.Ryan@walgreens.com

Innovative Models of Care - Walgreens Healthcare Clinics

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