January 9, 2009
Volume 53, Issue 1

Nursing Workforce Expert: "If there is a nurse in everyone’s future….will there be enough?"
WHA’s Warmuth, Maryland’s Allan share information on nursing workforce challenges

Wisconsin’s aging workforce and a shortage of nurse faculty are just two of the challenges Wisconsin faces as it grapples with a growing nursing shortage that will threaten access to medical services. WHA’s Judy Warmuth, vice president of workforce, joined Janet Allan, dean of the University of Maryland School of Nursing, as they presented information on both the state and national nursing workforce issues at a January 8 Legislative Briefing at the State Capitol. The briefing was sponsored by the University of Wisconsin Population Health Institute’s Evidence-Based Health Policy Project.

In her introduction of the two speakers, Katharyn May, dean of the UW Madison School of Nursing, told the standing-room only gathering comprised of legislators, legislative staff members, and representatives from health care-related organizations, "The time for talk is over. It is time for action in Wisconsin." May advocates for more resources devoted to nursing education, and she is deeply concerned about having an adequate number of nurse faculty members to meet demand, a concern echoed by both presenters throughout the briefing.

Nationally, more than 40,000 qualified nursing school applicants were denied admission to nursing school in 2007–2008, which quickly becomes a vicious cycle of fewer nurses-fewer faculty-fewer nurses…according to Allan. Allan suggested that the faculty shortage can be alleviated through advocacy efforts on a federal and state level, educational partnerships, academic innovation, and external funding. One of the biggest barriers to nurses entering teaching is the pay differential, with nurse faculty members typically earning much less than nurses employed by hospitals.

Allan said the national RN vacancy rate is 8.1 percent, but in her home state of Maryland, it stands at 13.5 percent. Allan said with more than a half million nurses needed by 2025 and the fact that demand does not keep up with supply now in many parts of the country, more than 80,000 new nurse graduates are needed every year.

"Technological advances have not replaced the need for nurses at the bedside. In fact, in some areas such as neonatal intensive care units, advanced technology requires one nurse to each patient. Acuity is very high in today’s hospitals," Allan said.

Allan said 41 percent of the nurses working are over 50 years old, while in 1980 it was 25 percent. As nurses become older, the type of work they can do changes, an area Warmuth said has garnered attention in Wisconsin. For example, Warmuth said the Governor’s Select Committee funded a pilot project on safe lifting practices, and Wisconsin hospitals have devoted resources to redesign the work environment to accommodate the needs of an older workforce.

"We don’t want to lose our more mature nurses—they have institutional knowledge as well as the experience that is absolutely necessary in today’s complex health care environment," Warmuth said.

According to Allan, a nursing shortage creates more barriers to access, drives up health care costs, and drives down patient and health care employee satisfaction scores.

Warmuth credited the nursing schools in Wisconsin with doing a "phenomenal job" of increasing capacity.

"We have a lot of great nursing programs in the state," according to Warmuth. "But, their question to me continues to be: ‘How many nurses does Wisconsin need and when are they needed?’ Unfortunately we can’t answer that question because we don’t have the data," she added.

Sen. Judy Robson weighed in on the same later by saying she thought there should be a mandate that nurses supply workforce-related data when they renew their licenses. Along with that, Sen. Robson said a coordinated system should be in place to analyze the data collected from nurses, suggested that might be a proper role for the Wisconsin Center for Nursing.

"Nurses are the backbone of our delivery system. We absolutely need to know more about the workforce. If we have a serious problem-which we do-lack of data is a barrier to solving it," according to Robson.

The Briefing was videotaped for broadcast on Wisconsin Eye, which along with the presenter materials, will be available soon at this link: www.pophealth.wisc.edu/uwphi/publications/forums/events.htm.

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FEDERAL UPDATE: WHA Weighs in on Economic Recovery Package
Medicaid matching rate, HIT among issues still in play

In what will likely be a six-week sprint to finish an economic recovery package, the Wisconsin Hospital Association weighed in with Members of Congress this week on important issues in play in a recovery package.

Of primary interest, WHA urged that a recovery package include an increase in the federal Medicaid match rate (FMAP) for states along with meaningful maintenance of effort criteria. During a time when Medicaid programs are seeing an influx of individuals, investment in Medicaid would not only recognize the counter-cyclical nature of the program but also its role in providing a health care safety net for millions of Americans. WHA believes a significant increase in the FMAP will help ensure that states have adequate resources to maintain eligibility, a full range of needed benefits and access to providers in these hard economic times.

WHA stressed it would be essential to condition a state’s receipt of the increased federal investment on a pass through to local governments commensurate with their contributions to the non-federal share and a robust maintenance of effort to protect against adverse changes in eligibility, benefits, provider payments or access to care.

Also still in the mix for possible inclusion in a recovery package are provisions addressing health information technology, including onerous privacy provisions. WHA has previously expressed concerns with these provisions and opposes their inclusion in the economic stimulus package. Wisconsin hospitals and health care providers are concerned that these provisions would create new administrative burdens and costs to hospitals and health care providers using electronic medical records, and consequently create a substantial barrier to the further adoption of electronic medical records. Furthermore, the consent requirements in particular would create significant new barriers to quality improvement activities in Wisconsin, including public reporting initiatives.

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WHA Moves to Make Greater Use of Electronic Communications

For decades, WHA has produced a newsletter on Fridays and printed and mailed hundreds of copies. After convening a workgroup and reviewing our communications vehicles, the decision was made to begin to reduce the Association’s dependence on paper and send more communications to members electronically.

"With our hospitals all deploying more practices that conserve natural resources, we took a hard look at our own processes and found several opportunities we can take, especially in the area of printing, where we can reduce our use of paper and still deliver a high quality communications product in a timely manner to our members," according to WHA President Steve Brenton.

Each WHA member hospital and system CEO will continue to receive the Friday Packet that will include a hard copy of the newsletter. However, all other recipients of the newsletter will receive WHA communications, including the Friday newsletter, "The Valued Voice," by email only starting February 6.

If you are currently receiving a hard copy ONLY of The Valued Voice by mail and wish to receive it by email starting February 6, contact Tammy Hribar at thribar@wha.org, or 608-274-1820. The Friday Packet is also available 24/7 from the WHA Web site at www.wha.org. The current issue is on the home page of the Web site, and past issues can be found in Publications & Archive.

If you have any questions, contact Mary Kay Grasmick, WHA, at 608-274-1820 or mgrasmick@wha.org.

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CMS Announces Noridian to Administer Medicare Claims in Wisconsin

The Centers for Medicare & Medicaid Services (CMS) earlier this week named five Medicare administrative contractors (MAC) to process and pay Part A and B claims in 14 states. The MACs, the last to be named under contracting reform provisions of the 2003 Medicare Modernization Act, will assume full responsibility for processing Medicare fee-for-service claims no later than March 2010.

Noridian Administrative Services, LLC has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Wisconsin, which is part of Jurisdiction 6 that also includes Illinois and Minnesota.

According to CMS, Noridian will immediately begin its implementation activities and will assume full responsibility for the claims processing work in Jurisdiction 6 no later than March 2010. During the implementation period, Noridian will conduct extensive outreach to health care providers to provide education and information about the implementation.

To learn more about Noridian, see their Web site at https://www.noridianmedicare.com/.

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Register Now for WHA Physician Leadership Development Conference

Take advantage of "early bird" discount pricing by registering today for the 2009 WHA Physician Leadership Development Conference. The discount pricing is available to individual physicians and hospital teams until January 23.

This annual conference is for new, potential and seasoned physician leaders, and will be offered by WHA on Friday, March 13 and Saturday, March 14 at The American Club in Kohler. Registration information is included in this week’s packet. Online registration is available at www.wha.org.

This popular conference offers nationally-recognized, CME-qualifying education necessary to develop physicians’ leadership skills and make the transition from clinician to physician leader at both a reasonable price and with more limited travel time and expense than the national conferences. The 2009 agenda, presented by faculty from the American College of Physician Executives (ACPE), will focus on strategic planning/marketing and dealing with disruptive physician behavior, and is based on WHA member and past attendee feedback.

Any physicians new to their leadership roles or who have leadership/management interest or potential should plan to attend this conference. Also, chiefs of staff, medical directors, chief medical officers, new medical presidents, new clinical department chairs, and new committee chairs are encouraged to attend or designate a physician with leadership potential to attend, as part of your organization’s succession planning. Finally, seasoned physician leaders who are looking for new ideas or perspectives are also encouraged to attend.

ACPE is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. ACPE designates this educational activity for a maximum of 12 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Additionally, these programs are part of the ACPE and CCMM requirements toward a graduate degree or certification in medical management.

The full conference brochure, with registration and resort information, is included in this week’s packet. For more information on registration, contact Lisa Geishirt at 608-274-1820 or email lgeishirt@wha.org.

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President’s Column: Hospitals’ Community Benefits in Spotlight Again

Iowa Senator Chuck Grassley is again calling for minimum hospital charity care thresholds in order to "earn" tax exempt status. As noted in a December 18 Wall Street Journal article, "Grassley Targets Nonprofit Hospitals on Charity Care," the populist Republican Senator "is weighing proposing legislation in early 2009 that would hold nonprofit hospitals more accountable for the billions of dollars in annual tax exemptions they enjoy."

Grassley’s definition of "accountable" may feature a minimum, hospital-specific threshold for charity care. Apparently, graduated penalties would be imposed on hospitals that fail to meet the requirement. In the past, Grassley has suggested that hospitals spend at least five percent of their patient revenue on charity care. That minimum is actually lower than numbers proposed in recent years by Illinois Attorney General Lisa Madigan.

Fiscal year 2007 data indicates that Wisconsin hospitals, in aggregate, spent 1.57 percent of their net revenues on charity care (based on actual costs) and 1.67 percent of their net revenues on bad debt for a statewide aggregate total of 3.24 percent. Recent member survey data indicates that that percentage is probably higher for 2008.

It’s important to note that the Grassley position does not appear to be a majority opinion in Congress. But his persistency in pursuing a minimum charity care mandate (along with curbs on executive compensation and benefits) will generate a lot of press attention in coming months. And there are other important lawmakers like Congressman Pete Stark (D-California) who share Grassley’s worldview.

The takeaway here is that Wisconsin’s community hospitals must reinforce and increase their efforts to talk about the special role they play in providing community benefits, especially to vulnerable populations. As noted repeatedly in Valued Voice stories, you have much to share. Minimally, hospital specific transparency will increase substantially over the next few years. As with other important public reporting endeavors like CheckPoint and PricePoint, it will be important to stay in front of the heightened expectations and expected accountability.

Steve Brenton

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AHA Announces Schedule H Project

The AHA will be collecting "mock" or "dry run" Schedule H forms from tax-exempt hospitals until March 15, 2009 to help members better understand and prepare for the actual Schedule H filings, sometime next year. To do so, the AHA is working with tax-exempt specialists at Ernst & Young to collect and analyze information from the "mock" Schedule Hs.

Schedule H is a brand new IRS form for reporting community benefit activities that tax-exempt hospitals will need to complete and file for tax year 2009. The IRS has never tested the form, so there are many uncertainties about its strengths and weaknesses in accurately conveying to the government and the public the wide range of benefits that hospitals provide to their communities. To help the field better understand and prepare, AHA is asking hospitals to participate in the AHA’s Schedule H project.

The AHA is asking hospitals to share "mock" Schedule H filing with AHA by no later than March 15, 2009. Any hospital that wants to participate will complete Schedule H (using 2007 data), as if it were being filed with the IRS, but instead share it with Ernst & Young, so that the firm can review and analyze the responses. Each participant in the project will receive a concise benchmark report summarizing the responses of similar hospitals to certain questions, such as the amount of unreimbursed Medicaid expenses and the use of the federal poverty guidelines for charity care eligibility. Participating hospitals would be able to see, in the aggregate, how other similar hospitals had responded. For example, a rural hospital would see aggregate results for rural hospitals and/or aggregate information from other hospitals in its state or region. No participant names would be disclosed in the report.

The AHA will use the information from the "mock" Schedule H forms to provide feedback and best practices to the field that will help to improve Schedule H filings for tax year 2009. A copy of the AHA announcement and more details of this project are available on the WHA Web site.

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WHA Co-Sponsors "Business Day in Madison" on February 11

The Wisconsin Hospital Association joins other groups once again in co-sponsoring the 2009 "Business Day in Madison." This annual event brings business leaders from across the state to Madison to learn about issues impacting the business community, meet with their legislators in the State Capitol and network with one another. This year’s event takes place at Madison’s Monona Terrace on Wednesday, February 11.

With so many important economic and business issues in play this year, WHA co-sponsors and participates in Business Day as part of its overall advocacy strategy to collaborate with others in finding solutions to these current policy challenges. Watch for more details on the issues WHA will be highlighting at this year’s event.

Keynote speaker for Business Day is Dr. Charles Krauthammer, columnist with the Washington Post and Time magazine, who will provide attendees his first-hand insights into the state of international affairs today.

Contact Jenny Boese at 608-268-1816 or jboese@wha.org if you plan to attend this event or for additional information. For a copy of the registration form, please log onto www.wha.org/SpeakUp/2009Businessday.pdf.

Important Note: Business Day in no way duplicates nor takes the place of WHA’s premier legislative grassroots event, WHA’s Advocacy Day, to be held on April 1 in Madison. Some 600 hospital leaders, employees, trustees and volunteers from across Wisconsin are expected at this year’s event. Details to follow in next week’s Valued Voice.

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WI Hospital Emergency Prep Program Issues Disaster Credentialing Toolkit

In 2009, the Joint Commission is moving the standards for disaster credentialing for Volunteer Licensed Independent Practitioners (Medical Staff Section) to EM.02.02.13 and the standards for Volunteer Practitioners (Human Resources Section) to EM.02.02.15. These standards include documentation, measures of success and direct impact requirements.

The Wisconsin Hospital Emergency Preparedness Program has prepared a toolkit that provides guidelines to help hospitals meet these standards along with a Web-based application that enables hospitals to do real-time primary source verification. The toolkit is available on the Wisconsin Hospital Association’s Web site under Disaster Prep (Volunteer Credentialing for Hospitals) and also on WI Trac under the Knowledgebase (click on WI Trac Library, then Patient Clinical and Support Activities).

The toolkit contains the following by file name in a WORD document format so hospitals can adapt these guidelines into a hospital policy:

Further tools that will be added to the toolkit, at a future date, include:

For more information contact Dennis Tomczyk, director, hospital emergency preparedness, Wisconsin Division of Public Health, at 608-266-3128 or dennis.tomczyk@dhs.wisconsin.gov.

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Community Benefits: Stories From Our Hospitals - Gundersen Lutheran Health System, La Crosse
500 Club helps people eat healthier

We are all familiar with the growing statistics about American’s growing waistlines. One of our biggest concerns—and challenges—is influencing healthier lifestyles in people in the communities we serve. Gundersen Lutheran’s Nutrition Therapy department, in an effort to combat the disturbing obesity trend, developed our innovative 500 Club® program.

The physician-endorsed 500 Club is a healthy eating program coordinated by Gundersen Lutheran registered dietitians. They work with area food retailers to help consumers make smarter, healthier food choices. The 500 Club partners include grocery stores, restaurants, quick-service counters, a take-and-bake business, delis, even convenience stores and a vending machine company.

To take the guesswork out of selecting healthier, great-tasting food, consumers only have to look for the green 500 Club logo on food products at dozens of area locations (a listing of 500 Club members is conveniently found on the Web at www.500-club.org). The green 500 Club stamp of approval means the selection contains approximately 500 calories or less and is controlled in fat.

There used to be a fee for 500 Club members but because of the importance of the mission of the 500 Club, the program is now free for members and consumers alike. The only commitment is to enjoy a healthier lifestyle.

500 Club for Kids is also offered at select 500 Club member restaurants. This program helps children and parents make nutritious choices when dining out. 500 Club for Kids menu items don’t focus on calories but instead offer healthier side selections such as fruit and vegetables.

Snack healthier, too
. In area vending machines, the 500 Club logo (or green "pushers") identifies snack items that are approximately 200 calories and 8 grams of fat per serving.

500 Club grocery store tours. To help people better navigate local grocery stores, our 500 Club program offers free tours in cooperation with 500 Club-member grocery stores. The goal of the tours is to teach consumers how to:

Turning our attention inside our own facilities

While we work to expand our area of influence with our 500 Club, Gundersen Lutheran dietitians have also focused attention closer to home—to our own nearly 7,000 employees—to help them make healthier food choices, too.

Fruit and vegetables for a quarter. Few people seem to eat the recommended three to five servings of fruit and vegetables every day. In an effort to help employees meet their goals for better nutrition, we began offering apples, oranges, bananas and individual bags of baby carrots to employees for only 25 cents. We’ve heard from several employees that, given a choice, the 25-cent fruit is preferred to higher calorie, higher fat snack offerings. Sales of the fruit and vegetables support this view.

Vending machine makeovers. We worked with our local vending machine vendor (also a 500 Club member) to stock all the vending machines in our facilities with additional healthier snack options. During a special sampling day, employees could sample and vote on the snack choices they wanted to see offered. We then negotiated a substantially lower 50-cent price for the healthier snacks compared to a dollar or more for the higher calorie candy and chips. Sales show that when offered affordably priced, healthier snacks, employees will make the better choice.

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Community Benefits: Stories From Our Hospitals - St. Mary’s Hospital Medical Center, Green Bay
Patient Stories

I was so scared and had nowhere to go

"I knew something was wrong and I was so scared. I had nowhere to go. I cannot get health insurance because of my health problems so I don’t go to the doctor until my health gets terrible for me. I finally had to go to the doctor; he knew I needed some tests for an ovarian cyst and fibroid tumor. I am disabled and am raising five children so there was no money for these tests. I am also diabetic and I go without insulin sometimes because I cannot afford it. My doctor reassured me, ‘Don’t you worry, we’ll figure it out.’ He called all over to find care for me; one hospital wanted $2,000 up front and I could not afford it. He finally called St Mary’s and then called me back cheering, "We found a place – you can go to St Mary’s!" I was so scared that I had something really wrong and I was treated so nice. It happens sometimes, that when you can’t pay you get treated poorly, but when I came to St. Mary’s they didn’t care that I didn’t have the money—they only cared about me. The lady doing the CT scan was so kind, so nice. I appreciate how I was treated and it was such a relief to find a place that would take me."

Expressions of thanks and gratitude

"I want to thank you very much for your help with my account to be approved for the Community Care Program. When I received the letter from St. Mary’s waving the balance, I cried happy, relieved tears. I never in my life thought I’d be in the position I’m in at my age, but I know there are many others like me. You took a huge weight off my shoulders and made my day and more. Thank you so much again."

"To all at St. Mary’s: I graciously thank you, everyone, for the wonderful care you gave during and after my stay at your outstanding facility. I never expected to be treated that well anywhere. Everyone I met made me feel at home and completely welcome. And a very special thank you to the Community Care Committee that was able to see the dilemma my husband and I are in. There are just no words to say how grateful we are. Again, thank you."

"Received your letter and statement "Paid in Full" with heartfelt gratitude. I am at a loss of words to express how I feel at this time! Thanks to St. Mary’s, I can plan and think about my future."

Stories from "A Woman’s Place" at St. Mary’s Hospital Medical Center, Green Bay

Anna, a young woman who stopped by A Woman’s Place just for some information about pregnancy, had never seen a doctor before. Our counselor suggested she go over to get checked at our partner clinic and, to everyone’s surprise, she was admitted the same day. Her baby was delivered a few hours later.

Juanita, who spoke no English, told of having to be accompanied by her 10-year-old son when she made prenatal visits to the doctor—her son had the uncomfortable job of translating her symptoms for her. Now she meets with our Hispanic health educator who helps her navigate her health care.

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Community Benefits: Stories From Our Hospitals - UW Health Partners Watertown Regional Medical Center, Watertown
Heart health screenings

While heart disease is the leading cause of death among women, many women are not aware that they can reduce cardiovascular disease risk as much as 82 percent by managing risk factors and leading a healthy lifestyle.

With a "Know Your Numbers" message, UW Health Partners Watertown Regional Medical Center provided free heart health risk assessments to 100 local women. These women received blood pressure, total cholesterol, HDL cholesterol, diabetes, and weight screenings. Using the Framingham Heart Study definitions, each woman received a "High, "Moderate," or "Low" risk score, as well as immediate consultation with an exercise physiologist to create a care plan based on their risk factors.

With this particular program, 16 women were identified as "moderate" risk, and eight women identified as "high" risk. By "knowing their numbers," these women were empowered to make healthy lifestyle changes, consult with their physicians, and to seek any follow-up care necessary to prevent cardiovascular disease.

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Community Benefits: Stories From Our Hospitals - Aurora Sinai Medical Center, Milwaukee
The Healing Center

The Healing Center was created as a natural extension of the Sexual Assault Treatment Center at Aurora Sinai Medical Center. Nearly 25 years of emergency treatment, forensics and short-term follow-up care revealed the need for a program dedicated to serving survivors of sexual assault and abuse.

Because the path to true healing is different for every survivor, a combination of specially trained counselors, advocates and volunteers help each survivor build upon inner strengths, release the shame of an abusive past and find hope and inspiration in the success of others who have gone through—and beyond—similar trauma.

Through every stage of the healing journey, traditional therapies, such as individual counseling and group-work, are complemented by a constellation of alternative modalities including art and writing workshops, massage, bodywork sessions and movement classes, tai chi and yoga. Often, these non-traditional therapies accomplish what talking alone cannot.

In their lifetimes, one in three women, and one in six men, will be sexually assaulted. Abused women use medical services at a higher rate than non-abused women. Besides medical issues, the lifelong toll on survivors is far reaching, affecting personal and professional relationships and survivors’ productivity, ability to trust, and ability to make healthy choices in all aspects of their lives.

Wanda is a survivor who has been battling addictions for years. At The Healing Center, she participates in a group called "Survivors Toward Recovery," and is maintaining sobriety as she works to confront her truth. In her own words:

"Even with my strong belief in a higher power, I still couldn’t find the answer to why I hated myself. I feel safe at The Healing Center. It’s terrifying to admit the truth without using alcohol or drugs. Discovering the truth causes great pain. But I am learning techniques to get unstuck from emotions and flashbacks. I don’t want to pretend anymore. I need what I am getting from The Healing Center."

Participants come from all walks of life. Although smaller in number, male survivors also participate in programs at The Healing Center.

The Healing Center was incubated by Aurora in 2001. Today, it is a freestanding agency located on Milwaukee’s near south side, supported by grants and in-kind services from Aurora Sinai Medical Center and Aurora Health Care. During 2006 The Healing Center provided 533 sexual abuse victims with free counseling, group, and advocacy services; provided intensive training to 50 peer advocates, and conducted community education at 44 events, reaching 2,030 community members. Community Partners include: Benedict Center, Mental Health Association, Latina Resource Center, CORE/El Centro, Task Force on Family Violence, community therapists and drug/alcohol counselors, Milwaukee District Attorney’s Office, Milwaukee Sensitive Crimes Division.

The Sexual Assault Treatment Center at Aurora Sinai Medical Center also is supported with a combination of in-kind support from Aurora and grants.

Submit hospital community benefit stories to Mary Kay Grasmick, editor, at mgrasmick@wha.org.

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