REACH FOR IT!

March 2023 Blog

What a Difference a Year Makes

Last year when NNPEN polled NP Value Summit attendees, they didn’t see Value Based Payment [VBP] at their doors for 10 years: Not a surprise. No payers were offering VBP contracts to NPs, and NPs felt a very low sense of urgency to leave FFS, the devil they knew.  But 12 months later, as of January 1, there are >100 payers willing to contract with NPs on VBP terms—a payer or two in most states. 

Q: Who are these payers?  A: REACH ACOs

REACH ACOs are the new Medicare payers for NPs, a five year pilot of CMMI focused on delivery of primary care services that create health equity and extend the reach of primary care into underserved populations—an NP sweet spot. [ REACH stands for Realizing Equity, Access and Community Health.]

And they are the NP friendliest of the CMS ACO models thus far—for one threshold reason [aside from NP’s love affair with seniors, especially high needs homebound beneficiaries]: REACH ACOs level the playing field for all eligible PCPs, docs and NPs alike—with a claims-based assignment system called Attribution also known as Alignment].  Attribution means eligibility for any auto-assigned revenue stream associated with traditional Medicare patients for the NP and any ACO s/he is part of.  By recognizing the NP in larger numbers through claim-based auto assignment [in addition to current voluntary assignment] as both the treating and billing provider, REACH creates visibility for NP PCPs and data to quantify NP value.

We already have that with our traditional Medicare patients that we see in our nurse-led practices…right?  Not really.  NPs are still stuck in a FFS payment system that is fiscally unfair, not patient-centered and affords little opportunity to grow into a practice big enough—visible enough—to leverage payers into reimbursement contracts that value NP quality and cost outcomes.

Like other ACOs, REACH creates critical mass leverage by aggregating—but not owning—small practices, creating a powerful Double AA battery of Attribution and Aggregation.  And with CMS as overseer and financial reconciler, REACH offers transparency and training wheels to accepting both risk and reward for your panel’s health . 

How does REACH support the NP’s shift to value?

• o   You keep your non-REACH patients and bill them as usual, direct to Medicare
• o   Monthly care management payments
• o   Monthly payment advances to support cash flow [“capitation”]
• o   Value-based payer contracting and population health program management
• o   Downside risk protection
• o   Access to shared savings
• o   Opportunity to erase the 15% differential with the Medicare physician rate schedule

There are 3 types of ACO REACH but all abide by same CMS/CMMI rules.   How do I tell these REACH ACOs apart? 

• o   High needs beneficiaries only: typically HCC >4.0; minimum ACO size=500 attributed lives
• o   Standard: established Medicare expertise; 5000 attributed lives
• o   New Entrant: New as Medicare providers; 3000 attributed lives with growth timeline

REACH ACO Nurse Practitioner Services Benefit Enhancement New in 2023

Wait—one more NP friendly change!  One of NNPEN’s members points to another way REACH ACOs will impact both the NP and the beneficiary, and in a much more immediate way.  Through the Nurse Practitioner Services Benefit Enhancement 2023 the NP can certify the need for hospice, diabetic shoes,  cardiac rehabilitation and several other therapies WHICH STILL REQUIRE PHYSICIAN CERTIFICATION FOR MEDICARE BENEFICIARIES NOT ALIGNED WITH AN ACO REACH.  This is a benefit the REACH ACO can elect to offer in an effort to streamline both quality and cost for seniors.  This benefit enhancement works for the patient [diabetic shoes today!] and also supports ongoing collection of quality and cost data starting this program year, and we know that data is what we need to change policy more broadly!  See page 75 in this link for a complete list of enhancement services: https://innovation.cms.gov/media/document/aco-reach-rfa

If you’ve railed against the barriers created by the physician certification of need requirements, recognize the REACH Nurse Practitioner Services Benefit Enhancement effective  2023 as another opportunity to create  the visibility NPs need to lay the foundation for quantifying NP Value.

Best ways to learn more about REACH ACOs

• 1.      Interviews with ones in your state; are they NP -friendly? Do they understand your questions? Have they shown willingness to negotiate a cap on downside risk? Have they elected to offer the NP Services Enhancement Benefits?
• 2.      Understand their timelines and match against yours
• 3.      Follow NNPEN’s REACH reporting and strategy to build a critical mass of like-minded NP practices
• 4.      Remember One and Done: Primary care providers cannot participate in >1 REACH at a time, but can withdraw
• 5.       Join us April 1, 2023 in person or virtually for our spring conference: [In]Visible* to Value, which will focus on creating NP visibility as a precondition to NP success in VBP, and hear how peers assess the downside risk of this migration.  Here’s the link to the NNPEN 2023conference landing page: https://mailchi.mp/2ed382004d0e/je04wxx0yw 

See you April 1 [no fooling!]

SB

POST 2022 SUMMIT BLOG

NP VBP: IS THE JUICE WORTH THE SQUEEZE?

NNPEN hosted its first Value-based Payment Summit on February 11^th and 12^th with attendance of 30+ like-minded professionals, all focused on NPs getting paid for the nursing model’s value add . Together the Summit ROCKED on content, every session recorded to reach a much larger audience.  NNPEN experts agreed that a fee-for-service model is unsustainable for nurse-led practices and NPs need to understand the benefits associated with an at- risk payment strategy.  With a focus on health promotion and disease prevention under a nursing model of health care delivery, the NP can survive and benefit from a value-based payment arrangement. Our narratives built one on another and made sense together: how often does that happen? We think this summit marks the beginning of a ground-up mapping to critical mass numbers! Many, many thanks to our subject matter expert speakers: researchers, payers, practice owners and educators.

We owe equal gratitude to the robust support NNPEN received from first-time sponsors, topped off with exhibits by the Emory Nursing Experience, a professional development initiative for nursing and Medical Advantage, a practice management company supporting NPs. These sponsors see the value of NPs in this space, even while we recognize NPs lag behind for many reasons revealed during the Summit sessions: lack of knowledge, small panel size and lack of incentives, to name a few.

The Summit concluded with these questions: How can we do this? How will we raise the value-based payment participation rate of nurse-led practices—and in turn, give NP practices agency over how they deliver the services their patients need, create sustainability both financially and clinically for their practices, and act with urgency?  NPs as a workforce cannot waste this opportunity to leverage the pandemic’s access crisis in each of the 50 states!

We have several takeaways to hold close as we push to construct the roadmaps to NP VBP model participation:

1.  NP attendance at the Summit tells us there’s more work to be done to move the value- based payment needle for NPs – not in 10 years’ time [the most common chat response on timing of VBP’s arrival for nurse-led practices] but starting now.  Policy wonks, including CMS, peg the transition timeline closer to 3-5 years.

2.  VBP covers services that are patient-centered, not volume driven, and aligns with the patient-centered nursing model.  Sharing values with payers bodes well for patient-centered partnerships—not so much with FFS payers that reward volume

3.  Our biggest risk is NOT down-side risk, but NP failure to plan for a transition to VBP that will be here, championed by Medicare and employers, in the frequently cited timeline of 3-5 years.

4.  We know that nurses are bottom-up problem solvers [because there has always been resource constraint in conflict with what our patients need?].  So, we need to get local NP organizations talking with each other, with a common agenda, to ultimately answer this one meta question: IS THE JUICE [THE TRANISITION TO VBP] WORTH THE SQUEEZE?  WHO DECIDES? Remember if we are not at the table, we are on the menu!

How will this happen?  NNPEN will edit the recorded Summit sessions, summarize a bit, and then invite partners on a local level to draft a consensus vision for NP VBP and to propose next steps, including sources of funding, that fit the region and that will lead to region-specific answers to our meta question, “Is the VBP Juice worth the Squeeze?”. 

We are also looking for other stakeholders who see the need for action to join us.  Is this too much to ask?  We don’t think so.!!

Sandy Berkowitz, Lynn Rapsilber, and Lorraine Bock

NNPEN

Value based payment (VBP) can be scary. Many NP practice owners have grown up under the fee-for-service (FFS) reimbursement structure.  As we are seeing and will continue to see, payment is shifting to  value-based payment (VBP) models.  The goal of VBP is to control costs through keeping patients healthy-- preventing disease and optimizing level of wellness. Does this sound familiar? Nursing is rooted in health promotion and disease prevention-- the hallmarks of VBP.  So then why are more NP practice owners not embracing this more sustaining (clinically and financially) payment model? Let’s look at some of the reasons.

First, NP practice owners start their businesses with small patient panels, perhaps working just one day a week.  This inhibits NP practice owners from reaching the critical mass necessary to participate in VBP programs.

Second, NPs tend to be bottom-up problem solvers.  Being on the front line of care delivery, we focus on the immediate solution that works for the patient. That is also how we solve problems with our practices.  NP practice owners need to know their practices will not be compromised, fearful of consolidation efforts that have not worked for other providers.  We have slim margins and fear being corralled into the potential for  financial loss .  Currently, there exists no incentive for NP practice owners to  create critical mass to participate in VBP programs. We don’t yet see that  the potential for gain is increased, not decreased,  by the patient-centeredness of our shared nursing model.

Lastly, NPs have a tendency to “make-do”.  For this reason, nursing’s blessing is also its curse. With our nature to make do, we preserve the status quo.  We miss out on opportunities that capitalize on the value that the nursing model truly offers.

How do we elevate NP practice owners to risk takers and valued participants in VBP?  What creates enough incentive for NP practice owners to color outside the lines of FFS?  How do we leverage what we know about how nurses problem-solve to produce informed risk takers?

These are the very questions we will confront together at NNPEN’s  NP VBP Virtual Summit on February 11^th and 12^th.  These are questions we must answer; our time is NOW.  So here’s my first message as NNPEN’s CEO to Nurse Practitioner practice owners and the resources that support them:

BE A PART OF THE START!!  Join the Summit's payment conversation and post-Summit building of road maps to nurse-led practice sustainability; we need you NOW! Here’s the Summit information link: CLICK

Dr. Lynn Rapsilber

Co-founder and CEO NNPEN

February 11, 2022 Friday Afternoon
& February 12, 2022 Saturday Morning

Four years ago, NNPEN’s founders were planning our first Nurse Practitioner Entrepreneur [NPE] Conference in Boston in collaboration with Northeastern University.  Nervously we watched the registration numbers limp along, shocked when nearly 100 NPEs and educators showed up.  Many still refer to that 2017 Boston event as the Ground Zero 1.0 of an NP practice owner [NPPO] community. Since then, NNPEN became an NP member services entity organized as an LLC with dreams of both profit and prophet. Among other things, we’ve fashioned from whole cloth an NP Business Basics curriculum, consulted with NP practices of an NP Aggregator, and convened signature conferences for NPPOs every year, including 2020. 
 
These past 4 years’ Ground Zero 1.0 work has been nurturing a community of NPEs who wonder if they are ready to be owners of their own practices [autonomous practice with no doctor oversight is lawful in half the states and growing].  Now nurse-led practice doors are opening but payers will not negotiate revenue unless NP practices are willing to accept downside risk as well as upside incentives in alternative payment models [aka VBPs, or value-based payments].  Payers, led by CMS, are leaning heavily toward APMs that reward patient-centered outcomes we know that Fee for Service contracts with NPs do not and will not.  Ground Zero 2.0 is about planning for this major risk-reward payment reboot, with NPs embracing the fiscal value of the nursing model’s “deliverable”: patient centeredness. 
 
We are trying to connect many data points into a realistic payment reform strategy with the hope that like-minded attendees at this Summit hear the same call to action we do.  Most of the sessions will feature non-NP subject matter experts, each paired with one or two NPPO [NP Practice Owner] respondents in a conversation that starts our program with Will the NP-owned Practice Survive?  NNPEN’s job is to keep the ball in play, to connect the Summit participants in the drafting of a post-Summit consensus plan, Roadmap to Critical Mass.
 
On February 11 and 12, 2022 please join us to celebrate our arrival at Ground Zero 2.0, NNPEN’s 2022 NP Value-Based Payment Virtual Summit.  We believe it’s time for NPPOs to develop their critical mass strategies and the road maps to get there.  And we also believe that the Ground Zero 2.0 Summit is the beginning of the community that will do that work. 
 
SB
Sandy Berkowitz
NNPEN Payment Reform Strategist

• It’s not that often that change and I see eye to eye—but welcoming NNPEN co-founder Dr. Lynn Rapsilber as NNPEN’s CEO on July 1, 2021 is one of those times.  Lynn is my dream-come -true to take the baton:  DNP, healthcare policy wonk, sought-after national Billing & Coding presenter, GI practitioner and tested consensus-builder!  And she knows that nurse-led start-ups have the power to solve the primary care access crisis in America.  She will drive NNPEN to answer this question:  How will that NP practice ownership explosion happen?

  In this win-win, Sandy relinquishes CEO responsibilities and takes on Priority #1 for me personally, and NNPEN derivatively, which is NP Payment Reform. To lean into this initiative, the post July 1 Sandy is tasked with driving an NNPEN payment strategy whose goal is expanded NP practice participation in risk-based Alternative Payment Models (APM).  Say what???

  We have worked tirelessly to reduce barriers to NP entrepreneur [NPE] practice ownership: finding collaborating physicians, health benefits options for NPEs and their families; and business basics course work accessible 24/7that lays a foundation for the  developing NPE business brain ...with more to come.  

  Looking back at earlier blogs, the need for payment reform has been lurking since NNPEN’s beginning.  To be concrete: out of a total of 15 website blogs I’ve written since March 2018, payment reform appears 9 times. Why?

  Because NO MARGIN NO MISSION.  When we first birthed NNPEN and put those words on a slide as our call to action, the return was puzzled looks from NPs.  The battle was/is Full Practice Authority [FPA] in all 50 states.  But the potential for practice ownership in FPA states soon ran into this reality: even with FPA, Fee For Service reimbursement is not a sustaining revenue base.  “Sustaining” as in paying your bills including your own salary, and having money left over [the margin] to invest in your mission of growing your practice, offering patient services you were educated to view as a piece of patient-centered primary care – not indulgences. And having time to engage with your patients!

  We know there are barriers to negotiating sustaining payment for NPs.  The big three are:

• 1.      Critical mass: can NPs, happy to finally be owners of their own practices, be persuaded to look beyond their practice walls to aggregation of distinct nurse-led practices and their compelling quality and cost outcomes data?  With NPs on so many different electronic health records, data aggregation, national or regional, is a costly challenge. How do we skin this cat?
•  
• 2.     Appreciation of the need to preserve nurse-led care and its framework, the nursing model.  We need enlightened payers who see that nimble small practices go to where their patients are and must be sustained to ensure a primary care access solution in America.  We then need payers to design APMs modified for small independent primary care practices, not just for the big groups and healthcare systems. 

•  

• 3.     NPs’ ingrained risk aversion culture, including aversion to value-based payment risk.  Maybe the pandemic has demonstrated that nothing is risk-free: when patient traffic stopped, FFS revenue stopped, while APM cash flow continued.  Let me share how Doug Watson, CFO of Dignity Health [featured in a panel convened May 2021  by HealthLeadersMedia.com to explore Balancing Risks and Opportunities in Value-Based Care] answered the perennial question of how a provider/practice will know it’s time to leave FFS behind:

“I believe it is important to look at what risk allows you to accomplish

in terms of delivering better value to decide how and when to proceed.”

NP practice owners recognize the gap between what patient-centered services their training would dictate for their patients and the scope of patient-centered services FFS payments allow. You will become informed risk-takers when delivering a broader basket of patient services is the only path forward consistent with the analytics of the nursing model.

So I have my work cut out for me—and that works for me.  Lynn says ditto. 

How grateful we are that the NNPEN board was and is unanimous that the time to lean in, to invest in accelerating the pace of sustainable nurse-led practice growth, is now.

Here we go!

SB

 

It’s 2021 and NNPEN is still vertical. And eager to act, to kick covid in the butt.  

As painful as the past year has been,  covid has been good to NNPEN in that instead of non stop travel the founders suddenly had time to collaborate  even as covid changed everything around us.  Demand for healthcare services as a result of covid has highlighted the NP’s ability to create access to healthcare services while delivering better care at lower overall cost than physician PCPs.  Many states waived scope of practice constraints like physician supervision on NP freedom to practice autonomously on an emergency basis and have not looked back. On January 4th, 2021, Massachusetts, a restricted state blessed NP autonomous practice with bipartisan FPA (Full Practice Authority) legislation.  Last  July  Florida, the second-largest Medicare market in the country, granted FPA status to NPs in primary care. 

NPEs are kicking in the FPA door state by state, and it is  swinging open. It is a call to action for NP entrepreneurs (NPEs) –for you, our members.   In turn, What support can our members expect from NNPEN in 2021?   

Our Goal #1 is acceleration of the pace of nurse-led practice startups, which in turn will lead to broader access to patient-centered health care services in America.   In short, we have made substantial progress [during lockdown!]  developing tools to accelerate our members’ transition from the pre-contemplation question of “Am I an Entrepreneur?”, through the Owner Go/No Go decision,  to the satisfaction [and terror ] as a practice owner that at last “I am the boss of me.”  We now offer Business Basics learning experiences that are modestly priced,  taught by subject matter experts both in and outside of nursing and accessible 24/7 These offerings fill a content void created by the flawed thinking that dismisses the need for an orientation to business in nursing education, and introduces NP practice owners to a like-minded NP owner community that supplements the member services NNPEN currently can provide.  Recall that NNPEN was created in 2017 in response to this question: 

To preserve the benefits of nurse-led care the number of nurse-led start-ups must grow substantially and operate sustainably…How will that happen? 

Putting one foot in front of the other has led us to some initial strategies.  But how do we know if we’re on the right track?  We measure.  We know that 2/3 of our NPE members are not practice owners.  Given our goal is to accelerate NPE transition into ownership we have to ask  “Are We making a difference?”   We will be answering that question using two metrics which we invite you to track with us—and even more important, to dialogue with us about what we could be doing better:  

1 .25% growth year over year in our membership 

2.  Positive trend in % of members who transition into ownership after joining NNPEN 

Our Goal #2 is Nurse-led practice participation in Alternative Payment Model arrangements. Full Practice Authority legislative success is pyrrhic victory if practices are not financially sustainable. Results from NNPEN’s 2019-2020 survey of NP practice owners, which we hope to see published in 2021, confirmed that NP practices typically choose inadequate FFS arrangements over APM options that pay performance bonuses but also carry modest financial risk. Not surprisingly, lack of education  about managing payment risk soundly beat out lack of willing payer partners as the biggest barrier to APM participation  As a result, preparation for risk-based payment reform has become one of our explicit goals for late 2021 and beyond.  Watch for new NNPEN workshops that link NP quality and cost outcomes directly to the nursing process, and that explain why NNPEN sees the nursing process as your practice’s reliable profitability PPE.  NPs who see RISK as a four letter word will become informed risk-takers because APMs make sense financially.  Our bookies are betting  on NP APM participation by 2023.   

Finally, these goals are only two of the  exciting developments that have been incubating since lockdown began.  My role will be changing as will Lynn’s.  We have brought on board Korrynn Lancaster as the staffer who keeps us connected to each other—and to you.  Hang in there as we roll out ways of connecting with you and for you that we never dreamed possible two years ago.  2021 is going to be a great year! 

SB 

Open Payments is a federal program, required by the Affordable Care Act, that collects information about certain payments that drug and device companies make to physicians and teaching hospitals for things like travel, research, gifts, speaking fees, and meals. It also includes ownership interests that physicians or their immediate family members have in these companies.  This data is then made available to the public each year on openpaymentsdata.cms.gov.  Guess who has been added to the list of Health Care Providers? Yep, we are!  So, what does this mean?

Have you had to sign in for a speaker program, a lunch program, a dinner program or at a conference? Have you received an honoraria or speaker or advisory board fee?  There is a value attached to the “gift” you just received.  These monetary amounts will now be reported by the supplying party.

The Open Payments Search Tool https://openpaymentsdata.cms.gov/ records payments made by drug and medical device companies to physicians and teaching hospitals…and now US!

A Fun Fact: Connecticut was the first state to require tracking of payments to NPs as part of the Sunshine Act with passage of Full Practice Authority in 2014.

How will this affect NPs?

All the compensation we receive in goods, services, honoraria are tracked and reported to the public.  This may deter NPs from participating in Pharma stuff. Yet, it may enlighten us in other ways.

The amount of $$ we receive in these “gifts” are far less than the MDs.  Once we see some of these discrepancies, it can provide fuel to fight equal pay for equal work.  It has always been my fight to be paid the same as the MDs for speaker honoraria:  we learn the same slide deck, we present the same deck, yet we receive ~60% less than our physician colleagues.  There is a fair compensation guide (anything but that) used by the drug companies to calculate this rate.  This now makes it obsolete.

What you can do?

You can and should register to participate in Open Payments by clicking link https://www.cms.gov/OpenPayments/Program-Participants/Physicians-and-Teaching-Hospitals/Registration

Once you are registered you can look at what is listed under your name to insure it is accurate and true. You have until the end of the calendar year, in which the data is first published, to review and dispute the reported information. Changes that drug or device companies make to the data (because of your dispute) will be seen publicly in the data refresh (usually occurring in January of the next year).

Sometimes I feel like I have nothing “new” to report to blog readers—yes,  we all get that.  Then  suddenly after a period of low profile, stars align and a clear re-visioning emerges that needs to be validated externally. 

That’s been happening for NNPEN over the past 6 months.  Our founding vision has been to connect NPEs w/ each other and with sustaining start-up resources.  But that really doesn’t describe an outcome, more like a process. We shifted gears to update the vision to something measurable: a performance metric.  Simply put, our vision has become to not only attract  as members NPEs who are assessing their readiness to be owners and connect them with each other; it will also measure the NNPEN model as an accelerator in the transition of NPEs into practice owners. 

We are betting the house on this re-visioning of  NNPEN  success.  Covid crises are terrible things to waste, and we haven’t.  During Q4 2020 we will greet a client’s inaugural NP cohort enrolled in a twelve-week Business Basics interactive online course developed by NPs and their advisors for NPs. The twelve-week course will be followed by a  period of mentorship that lasts at least through opening the NP practice’s doors.  Payor mix and sustainability of the practices will also be measured.

On the homepage of our website we share the question that has driven NNPEN from day one:

To preserve the benefits of nurse-led care, the number of nurse-led start-ups must grow substantially and operate sustainably…How will that happen?

We are getting closer to figuring out a cost-effective model to increase primary care access in this country:  our beta partnership of hi-tech Business Basics learning and lo-tech hand-holding is about to begin!  For all of us, it (hopefully)is a roadmap for proof of the concept that NPs’ cultural aversion to risk can be not only neutralized but leveraged to the practice and patients’ advantage.  

As I make calls to lapsed NNPEN members, I brace myself for recounts of how NNPEN has failed the member. Truth be told, those conversations still happen too often, which accounts for our 2021 strategic focus on how to enhance member-to-member dialogue supported by, but not filtered through, NNPEN.

But as Summer Solstice rolls over us and brings with it the temptation to believe COVID-19 is no longer a threat, what I hear in these calls is not how NNPEN has failed the member. Instead, it’s narrowly suppressed panic about whether an NP-owned practice will survive the pandemic. As of March 12, 2020, patient visits have plummeted in response to orders from state, local, and federal regulators to cease all elective and preventive care. FFS cash flow dried up [while cash flow for practices accepting capitation risk did not!]. One NP owner is in self-care retreat after watching her colleagues hoard PPEs. Some practices were not sufficiently insured by their business interruption policies, and face business recovery plans with a new appreciation for the impact of the “once every 100 years” event on supplies, medical records and patient access. All this is in addition to worries about patient and provider survival –literally—in the ongoing battle with an invisible virus that dares us to unmask.

Almost every practice owner I spoke with is planning to transition–partially or entirely–from brick and mortar office space to a virtual practice for some obvious reasons:

• Ongoing reduced costs.
• Telehealth has become mainstream, the quality of its encounters is “good enough” and improving, and cost is not prohibitive: the NP practice has choices.
• More patient access to the practice.
• More reimbursable patient encounters. [Will payors maintain their favorable reimbursement stance? Look to CMS but NNPEN thinks yes.]
• Less wear and tear on the practice owner.
• Less contagion risk.

What does successful transition from brick and mortar office operations to a virtual practice look like?

In May 2020, NNPEN invited Sam Lippolis, Telehealth Advisor, to get this conversation started with our Office Ours participants.

Click here to listen to the extensive and practical dialogue Sam provoked. If you are an NNPEN member, you may access the recording as often as you like, no charge.  If you are not a member, the recording is available to rent. 

With Sam’s permission, we’ve edited her remarks below. 

Shared Secrets for Telehealth (TH) Success

1. How do I grow my patient panel into a virtual practice?

a. Try Sam’s Post-it strategy to generate TH candidates from your current patient panel in 30 minutes.

2. Does my state’s regulations permit TH practice and reimbursement that is sustaining?

a. See the State by State map on Sam’s website.

3. Telehealth device options?

a. Integrated w/ EMR in one platform.

b. HIPAA-compliant Zoom=$199/mo.

4. Integrating telehealth [TH] into my current practice: how to work the virtual and the face to face practices together?

a. Workflow: being on time matters; it’s annoying to sit in any waiting room!

• Schedule TH visits first thing in morning and after lunch.
• Pre-visit prep!

b. Risks of blocking virtual time on your calendar:

• Not enough virtual patient volume.
• No room for non-virtual patient complaints assessment.
• Until you build volume, don’t do dedicated time blocks.

c. Phased approach to reach ideal schedule!!

5. Training and testing.

a. How does the patient connect to telehealth?

• Patient & practice support.

b. ALL staff need to understand the workflow/be comfortable w/ TH so all staff need training.

• Scripts [choreographed dialogue] are part of the preparation of staff.

c. Don’t waste billable time because TH access is untested on either patient or provider side.

d. Multiple practice sessions with different devices in different settings.

• Discover Internet dead spots in home and office.
  You may need to toggle between 2 different devices: ipad to see patient and EMR too.

6. Virtual patient visits volume.

a. Need to keep up volume to get comfortable with virtual encounter.

b. Virtual visit etiquette FAQ should be created for patients and staff.

c. Goal: 5 virtual visits/week.

d. Patient acceptance of virtual visit depends on how invitation is worded and if the practitioner extends the invite: 30-60% increased acceptance if practitioner, not staff, extends the invite!

7. Work-life fit.

a. Invest in attractive virtual practice setting aesthetic.

b. Good lighting, private space, not cluttered, quiet.

c. Breathe deeply!

Action Cures Anxiety

We are planning an invitation-only virtual Office Ours on July 28, 2020 8:00 p.m. Eastern. This program is for NNPEN member-- past and present --practice owners who are at that fork in the road called Virtually Brick and Mortar. Virtually Brick and Mortar is built around a presentation created by American-APN called “Integrated Digital Healthcare: Technology in the Time of COVID-19.” Part of the program has been approved by the North Dakota Board of Nursing; NNPEN practice owners --past and current members --who attend will receive 1 CEU. The discussion will explore how the evolution of nursing has prepared nursing to excel in this turbulent time, as well as the role technology and the digital experience plays for patients and providers. Additionally, we’ll take a closer look at independent practice and the nurse practitioner entrepreneur. Nurses who have been delivering virtual care and contributing to the development of a platform that integrates the electronic health record, telemedicine technology, and the technology to deliver remote patient monitoring through advanced Bluetooth technology will be available to answer your questions. Transitioning from brick and mortar by integrating telemedicine into your practice can serve as something of a lifeline. Let us give you the information you need to make it work quickly for you. Indicate your interest by clicking here.

Finally, is there NNPEN member interest in a Transitioning My Practice support group facilitated by a fellow NNPEN member? We know you may not have an ounce of energy left over at the end of the day, but support from a like-minded community is more than gratuitous—it’s critical! We know attending one more Zoom session may not be part your summer plan.  However, if you are interested in a Transitioning Practices support group, click here. No pressure!

In the meantime, remember Yogi Berra’s advice: “When you come to a fork in the road, take it!” While wearing your mask, of course!

Stay healthy—we need you!

SB

Sandy Berkowitz
Co-founder and CEO NNPEN

I’d like to recreate for those NP entrepreneurs who didn’t make it to Blueprint for Success: Building and Growing Your Home-based Primary Care Practice the energy and synergy that fueled the content of this February 2020 debut conference collaboration between NNPEN and HCCI—and what it can mean for you and for continuity of service homebound patients. And as luck would have it, Joe Flores, NP and attorney, set the table for us on starting house call practices the month before at our January 21 Office Ours virtual meeting.  Bottom line, you need to do some self-scrutiny before jumping in with both feet; the home-based care setting presents challenges. Joe was enthused about house call and HBPC opportunities within reach of the NP entrepreneur because they are low cost start up options that create a win/win for the NP practice owner and for the vastly underserved home-bound population.  Here’s a link to Attorney Flores’ January 2020 Office Ours recorded session. https://nnpen.org/Office-Ours.

NNPEN is a for-profit LLC, co-founded in 2017 by four determined nursing leaders who share the belief that America’s 250,000 nurse practitioners (NPs) are the key to primary care access in this country, and it is not immoral or even unbecoming for NPs to profit from solving access challenges.

We believe this is possible if we can incubate an ecosystem that connects aspiring NP entrepreneurs with each other and with sustaining start-up resources.

But our vision depends on three things:

1. Full practice authority
2. Value-based payment (VBP) contracts with payers that reward the quality and cost savings that reliably flow from the patient-centered nursing process and
3. Providers who, with support, learn how to lean into VBP as an informed risk-taking alternative to predictable --but not practice-sustaining --fee-for-service (FFS) payments.

We are constantly looking for partners on this journey who see this linkage of full practice authority, VBP and informed risk-taking as the win-win that it is.  HCCI approached NNPEN last year and they had us cold when they shared with us this powerful graph—that tells us that delivering primary care in the home setting is a path forward being considered primarily by NPs, and these NPs need support with clinical, practice management and ownership issues.

Through this lens (above) we undertook joint sponsorship of the February 2020 HBPC conference to cross-fertilize not-for-profit Home-Centered Care Institute’s (HCCI) professional development mission with NNPEN’s entrepreneurship agenda to produce  i) a well-defined HBPC practice ownership blueprint ii) to make start-up and sustainability iii) easier for you as a practice owner and iv) primary care access feasible for the 85% eligible but unserved home-bound population in this country—whether through a cash business, referrals from hospital discharge planners, or marketing to your local Medicare Advantage plans, this might be your market!

So what are some of the takeaways that will excite you?  Let me share, with HCCI’s permission, a few slides that highlight issues HBPC owners will inevitably face:

Michael Helle @Blueprint 0220

Hands-On @Blueprint0220

Laura Snider @Blueprint0220

Laura Snider @Blueprint0220

Payments Panel @Blueprint0220

BPlecner/LRapsilber @Blueprint0220

Cyber Security @Blueprint0220

A final takeaway: Home-based Primary Care can be an ownership opportunity with the Nurse Practitioner’s name written all over it.  HCCI is the very best at delivering your HBPC professional development training; find them at  www.hccinstitute.org.  NNPEN www.nnpen.org will support your ownership agenda. Check out both our websites.

So, drivers: start your engines…Entrepreneurship is simply Prochaska change management in an MBA outfit: You Got This!

SB

Sandy Berkowitz
Co-founder and CEO NNPEN