8 hours. Use the articles. I have all the articles for references Discuss 1 Identify a current healthcare policy in your current role that you would like to see revised. Why? What would be the projected outcomes? In our discussion question #1, we will be looking at current healthcare policies that need revision. As you are reflecting on your response, how does the healthcare policy affect you? How does it affect other stakeholders? One of the primary things to consider is being a nursing advocate. We are taught to be patient advocates but how many of us are actually nursing advocates? In becoming a nursing advocate expert, it is very important to understand the different modalities needed to successfully analyze a health policy. This week’s graded topics relate to the following Course Outcomes (COs). 4. Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (PO #9). 5. Analyze legislative process and the impact of special interest lobbies (PO #9 1. How have you seen the legislative process impact patient care in your nursing practice or in the practice of other nurse 2. Who are the stakeholders and how could they be used in political analysis that might be different from their use in political advocacy? 3. Can you discuss the strategies you could utilize for a stakeholder who might be utilizing illegitimate power instead of legitimate power? Improving Care Transitions An example of a well-written policy brief is presented here. It was developed by Health Affairs and the Robert Wood Johnson Foundation. Website resource: . The term describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions. Several new federal initiatives aim to encourage more effective care transitions. In addition, debate continues over how to restructure fee-for-service payments to motivate providers across care settings to work as a team to make transitions smoother. This brief examines the factors contributing to poor care transitions, describes the elements of effective approaches to improving patient and family experience with transitions, and explores policy issues surrounding payment reforms designed to address the problem. For years, health policy experts have identified poor care transitions as a major contributor to poor quality and waste. The 2001 Institute of Medicine (IOM) report, described the U.S. system as decentralized, complicated, and poorly organized, specifically noting “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.” The IOM noted that, upon leaving one setting for another, patients receive little information on how to care for themselves, when to resume activities, what medication side effects to look out for, and how to get answers to questions. As a result, the conditions of many patients worsen and they may end up being readmitted to the hospital. For example, nearly one fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted within 30 days; three quarters of these readmissions, costing an estimated $12 billion a year, are considered potentially preventable, especially with improved care transitions. There are several root causes of poor care coordination. Differences in computer systems often make it difficult to transmit medical records between hospitals and physician practices. In addition, hospitals face few consequences for failing to send medical records to patients’ outpatient physicians upon discharge. As a result, physicians often do not know when their patients have been released and need follow-up care. Finally, current payment policies create disincentives for hospitals to invest in smoother care transitions. For example, although Medicare does not allow hospitals to bill for readmissions that occur within 24 hours of discharge, it does pay full price for most readmissions that occur after that time. This means that the prevailing financial incentive for hospitals is to not expend resources on improving care transitions because a poor transition often leads to readmission, which generates additional revenue. Moreover, some analysts believe that Medicare and Medicaid payment policies have unintentionally created incentives to unnecessarily transfer patients back and forth between hospitals and nursing homes. Their suspicion is that nursing homes, which are primarily paid by Medicaid with generally low payment rates, unnecessarily transfer patients to hospitals to qualify for more generous Medicare payment rates when their patients return to them after discharge. Lending credence to this claim, researchers have found that states with lower rates of Medicaid spending on dual-eligible patients under age 65 (people who are eligible for both Medicaid and Medicare) have higher rates of Medicare spending on these patients, and vice versa, suggesting that providers are gaming the system. As mentioned, one of the biggest barriers to smoother care transitions is the fact that primary care physicians often have little or no information about their patients’ hospitalizations. A review of the literature published in the in 2007 found that physicians had received a hospital discharge summary about their patients, and had it on hand, in only 12% to 34% of first postdischarge visits. Even when discharge summaries are received, they often lack key information, such as test results, treatment course, discharge medications, and follow-up plans. The situation is even worse for those patients who have no usual source of care. Patients often do not consistently receive follow-up care after leaving the hospital. Among Medicare beneficiaries readmitted to the hospital within 30 days of a discharge, half have no contact with a physician between their first hospitalization and their readmission. ( shows 30-day hospital readmissions under Medicare as a percentage of admissions, by state.) Medicare 30-day hospital readmissions as a percentage of admissions, 2009. (From Commonwealth Fund [2009, October]. . Washington, DC: Commonwealth Fund.) This problem may be worsening because of an ongoing shift in practice patterns. Increasingly, outpatient primary care physicians are no longer visiting their patients when hospitalized, and hospitalized patients’ care is now being managed by hospitalists, physicians who only treat patients in the hospital. Although hospitalists are generally believed to have improved the quality and coordination of patients’ in-hospital care, their presence, and the removal of patients’ outpatient primary care physicians from the hospital, has led to an increased need for care coordination among providers that doesn’t always occur. Several models for improving transitions after hospitalization have been developed and rigorously tested. One of the most widely disseminated is the Care Transitions Intervention developed by Eric Coleman at the University of Colorado. This approach involves transitions coaches, primarily nurses, and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls over a 4-week period. The coaches promote development of patients’ skills in four key self-care areas: managing medications; scheduling and preparing for follow-up care; recognizing and responding to red flags that could indicate a worsening condition, such as the onset of a fever or worsening breathing problems; and taking ownership of a core set of personal health information by having patients brainstorm and ask their providers questions about their conditions or self-care routine. In a large integrated delivery system in Colorado, the Care Transitions Intervention reduced 30-day hospital readmissions by 30%, reduced 180-day hospital readmissions by 17%, and cut average costs per patient by nearly 20%. The intervention has been adopted by more than 700 organizations nationwide. Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of older adult patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36% and costs by 39% per patient (nearly $5000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients’ physicians and provides regular home visits with 7-day-a-week telephone availability. The Affordable Care Act contains several provisions that could improve care transitions. These include both carrots (financial incentives) and sticks (financial penalties). Among the carrot approaches, starting October 1, 2012, hospitals can receive increases to their Medicare payments if they achieve or exceed performance targets for certain quality measures, including whether they told patients about symptoms or problems to look out for postdischarge; whether they asked patients if they would have the help they needed at home; and whether they provided heart failure patients with discharge instructions. (See the Health Policy Brief published on April 15, 2011, for more information on improving quality and safety: .) Among the stick approaches, also beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) can reduce payments by 1% to hospitals whose readmission rates for patients with heart failure, acute myocardial infarction, or pneumonia exceed a particular target. According to a recent analysis by the Kaiser Family Foundation, more than 2200 hospitals will forfeit about $280 million in Medicare payments over the next year because of these readmissions penalties. The law also authorizes paying providers for care transition services as part of payments to primary care practices that operate as medical homes, practices that closely manage and coordinate the care of patients with chronic conditions. One demonstration project, which predates the Affordable Care Act, is the Multi-Payer Advanced Primary Care Practice Demonstration in which Medicare offers practices that have been formally recognized as medical homes in eight states up to $10 per beneficiary per month to cover the cost of medical home services, which include care transition planning. Another demonstration, the Comprehensive Primary Care Initiative, offers monthly payments to practices that average $20 per beneficiary in the first 2 years and then transitions to $15 plus the opportunity to earn shared savings in the last 2 years. Again, a portion of these programs are intended to compensate practices for the costs of care coordination and care transitions planning. In addition, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration will pay $6 per beneficiary per month to health centers that adopt the medical home model and apply for Level 3 medical home recognition, having the most stringent requirements, from the National Committee for Quality Assurance (NCQA) by the end of the 3-year demonstration. NCQA’s medical home standards ask practices to establish processes to identify patients admitted to the hospital, share clinical information with the admitting hospital, obtain patient discharge summaries from the hospital, and contact patients for follow-up care, among many other expectations. State Medicaid agencies can now offer providers enhanced reimbursement, such as through monthly care management payments, to cover the cost of “comprehensive transitional care” and other services if the practice qualifies as a “health home”; a practice that cares not only for Medicaid patients’ physical conditions but also helps them obtain such other services as behavioral health care and long-term care services and supports. Also, a 5-year, $500 million Community-Based Care Transitions Program pays organizations that partner with hospitals with high readmission rates to provide care transition services for high-risk Medicare beneficiaries. All-inclusive payments cover the cost of care transition services provided to individual beneficiaries in the 180 days following an eligible discharge plus the cost of systemic changes made by partner hospitals to improve care transitions. So far 47 awardees have been announced, and applications continue to be accepted. Participating organizations initially enter into 2-year agreements, which can be extended annually through the end of 2015. The Medicare Shared Savings Program for accountable care organizations (ACOs) will give groups of providers an incentive to coordinate care more closely to keep patients healthy and out of the hospital because they will be eligible to share in the savings they are able to generate relative to a spending benchmark. The quality metrics that must be met by ACOs to benefit financially under the program include six that pertain to care coordination, including preventing unnecessary hospital readmissions. (See Health Policy Brief published on January 31, 2012, for more information on ACOs: .) The Affordable Care Act also authorizes 5-year bundled payment pilots in Medicare and Medicaid to test whether making a single payment to one entity for services provided by several providers for an episode of care, such as a knee replacement, will give providers an incentive to work together to ensure that patients receive all the services they need, including hospital and follow-up care, in a more efficient manner. Managing care transitions to prevent costly hospital readmissions will be particularly important because, in the Medicare pilot, at least, the bundled payment will cover services beginning 3 days before a hospital admission for an eligible condition and extending 30 days after hospital discharge. Signaling the importance of care transitions to the success of these efforts, the Medicare pilot requires bundled payments to cover the cost of transitional care services. CMS’s new Innovation Center has begun accepting applications from providers interested in piloting four bundled payment models through a separate Bundled Payments for Care Improvement initiative. The Medicaid pilot, meanwhile, requires participating hospitals to have “robust discharge planning programs.” In addition, a new Medicare-Medicaid Coordination Office in CMS is charged with better integrating benefits for dual-eligible beneficiaries. It also works to ensure “safe and effective care transitions,” among other goals. This office has awarded contracts of up to $1 million each to 15 states to design models to coordinate primary, acute, behavioral, and long-term care for Medicare-Medicaid enrollees. CMS has also invited proposals from states to test two new payment models to better integrate care for this population and allow states to share in savings from these improvements. Twenty-six states, including the 15 states awarded demonstration design contracts, have developed proposals for this demonstration. The new payment and delivery system models are likely to focus on improving care transitions, among other strategies. (See the Health Policy Brief published on June 13, 2012, for more information on dual eligibles: .) The Affordable Care Act also requires the Department of Health and Human Services to develop and implement a plan by 2013 that would lead to reporting physician-level quality measure data on the new Physician Compare website ( ), including measures of the quality of care transitions. CMS has until 2019 to decide whether to conduct a demonstration giving Medicare beneficiaries financial incentives to seek care from physicians who score highly on these measures. The law also creates a $200 million, 4-year workforce development demonstration aimed at increasing the number of advanced practice registered nurses trained in care transition services, chronic care management, preventive care, primary care, and other services appropriate for Medicare beneficiaries. Taken as a whole, the inclusion in the Affordable Care Act of these carrots and sticks aimed at different types of providers suggests a tension over whom to pay and how to pay them to improve care transitions. On the one hand, the payment cuts that high-readmission hospitals nationwide will soon face create an expectation that hospitals take responsibility for improving care transitions using existing resources. But the fact that another program will provide new care transitions payments to hospitals and community-based organizations suggests that they may require additional resources to provide these services. And although physicians’ performance on care transitions quality measures will be reported on Physician Compare, no provision in the Affordable Care Act requires hospitals to alert physicians when their patients are discharged, typically the needed first step before a physician can become involved in a care transition. If these Affordable Care Act provisions fail to improve care transitions or if CMS decides to pursue other policies, the agency’s statutory authority gives it some additional options, as follows: • Under the Medicare physician fee schedule, CMS could create a new billing code that would enable physicians to bill for delivery of care transition services. In a proposed rule issued in July 2012, CMS would create a code to bill for care transition services delivered to Medicare beneficiaries in the 30 days following a discharge from a hospital, skilled nursing facility, or community mental health center. The code would apply to Medicare patients whose medical or psychosocial problems, or both, require moderate or high complexity medical decision making. To qualify for the new payment, physicians would have to obtain and review a patient’s hospital discharge summary, update the patient’s medical records to reflect changes in health conditions and ongoing treatments, and establish or adjust a patient’s care plan. Physicians would be required to communicate with a beneficiary or their caregiver within 2 business days of discharge to resolve medication discrepancies and inform them about possible complications. Whether physicians will consider the payment level assigned to this billing code adequate for the effort required, however, remains unclear. • Another policy option would be to add a care transitions measure to Medicare’s Hospital Inpatient Quality Reporting program, a pay-for-reporting program. Adding such a measure would create a modest incentive for hospitals to better communicate with physicians about patients’ hospitalizations, especially if CMS chose to include that measure in the subset that is displayed on the Hospital Compare website . If CMS wanted to further elevate hospitals’ focus on this measure, it could include it in the subset of measures it uses in the Hospital Value-Based Purchasing Program, the new pay-for-performance program for hospitals created in the Affordable Care Act and scheduled to go into effect in October 2012. A hospital-related care transitions measure has been developed by a group of physician specialty societies and endorsed by the National Quality Forum, a nonprofit organization that works with providers, consumer groups, and governments to establish and build consensus for specific health care quality and efficiency measures. This indicator, called Timely Transmission of Transition Record (measure no. 0648), measures how often a hospital sends a transition record to a patient’s physician within 24 hours of discharge. Having this information would allow primary care physicians to identify which patients needed follow-up care. However, hospitals may not welcome this additional reporting burden because transmittal of such records to outpatient physicians is not a billable hospital service, which means claims data cannot be used to easily calculate how often such transmittals occur. Instead, for hospitals that don’t have good electronic health record systems, labor-intensive chart reviews would be required to calculate such a measure. If CMS were to pay hospitals to develop discharge plans, discuss them with patients, and transmit them to outpatient physicians for follow-up care, the hospitals would have a greater incentive to perform these crucial activities. CMS could also then use the hospitals’ billing records for these services to calculate quality measures assessing how often the hospitals performed these important services. However, in the current strained federal fiscal environment, offering a new carrot to hospitals may have little appeal for policymakers. Indeed, because Medicare already gives hospitals lump-sum payments to cover all the costs associated with a hospitalization and because Medicare’s conditions of participation require hospitals to have a discharge planning process in place, policymakers may feel hospitals are already being paid for care transition services but are simply not performing them as routinely as they should be. • Another policy stick would be to further limit payment for hospital readmissions. For example, CMS could extend its current policy of not paying for Medicare readmissions that occur within 24 hours of a hospital discharge for the same condition to 72 hours, or even 15 or 30 days, postdischarge. Doing so would require carefully defining which readmissions would be ineligible for payments and how to account for co-occurring conditions. Already, hospitals as a group are upset about CMS’s decision to penalize them for certain planned readmissions because they do not think it adequately distinguishes between readmissions that are truly necessary compared to readmissions that are truly preventable. Given the current budgetary environment and the fact that Medicare is estimated to spend $12 billion per year on potentially preventable hospital readmissions, interest in improving care transitions to reduce Medicare spending is likely only to grow. Although some care transitions interventions have generated cost savings, uncertainty remains over how best to encourage providers to use these approaches. Evaluation of the changes brought about by the Affordable Care Act will begin filling gaps in our knowledge. And if the health care law’s approaches fail to make a strong enough case for providers to pay attention to care transitions, policymakers may want to explore bigger carrots and sticks. Bubolz T, Emerson C, Skinner J. State spending on dual eligibles under age 65 shows variations, evidence of cost shifting from Medicaid to Medicare. . 2012;31(5):939–947. Coleman EA. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. . 2003;51(4):549–555. Hackbarth G. . Medicare Payment Advisory Commission: Washington, DC; 2007, June. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians. . 2007;297(8):831–841. Kronick R, Gilmer TP. Medicare and Medicaid spending variations are strongly linked within hospital regions but not at overall state level. . 2012;31(5):948–955. Naylor MD, Aiken LH, Kurtzman E, Olds DM, rschman KB. The importance of transitional care in achieving health reform. . 2011;30(4):746–754. Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists and care transitions: The divorce of inpatient and outpatient care. . 2008;27(5):1315–1327. Tilson S, Hoffman GJ. . Congressional Research Service: Washington, DC; 2012. The Women’s and Children’s Health Policy Center. . . Health Policy Brief: Care Transitions, Health Affairs, September 13, 2012. Written by Rachel Burton, Research Associate, Urban Institute. Editorial review by Eric Coleman, Division Head Health Care Policy and Research, University of Colorado Medical Campus; Debra J. Lipson, Senior Researcher, Mathematica Policy Research; Ted Agres, Senior Editor for Special Content, Health Affairs; Anne Schwartz, Deputy Editor, Health Affairs; and Susan Dentzer, Editor-in-Chief, Health Affairs. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation. Reprinted with permission. Policy Options John F. Kennedy The importance of nursing to the delivery of high-quality health care has been recognized since the inception of the practice of nursing. Various factors contribute to the quality of nursing care including the expertise of nursing staff, availability of supportive personnel and other health professionals, good communication among the care team, and the nurse/patient ratio. It was not until the early 2000s that high-quality empirical research found consistent relationships between licensed nurse staffing and the quality of patient care ( ; ). Concerns about the effects of changes in nurse staffing levels in the 1990s, combined with the increasing influence of nursing unions, resulted in the passage of California Assembly Bill (AB) 394 in 1999, the first comprehensive legislation in the United States to establish minimum staffing levels for registered nurses (RNs) and licensed vocational nurses (LVNs) in hospitals. This bill required that the California Department of Health Services (DHS) establish specific staffing ratios. These were announced in 2002 and implemented beginning in 2004. Since then, other states and the federal government have considered developing regulations for nurse staffing in hospitals. In 2014, for example, Massachusetts passed legislation mandating a ratio of one or two patients per nurse in intensive care units ( ). Throughout the late 1990s and early 2000s, there was substantial debate about the changes in hospital staffing that had occurred in the 1990s and the effects of such changes on the quality of care ( ; ; ; ). In some states, legislators and regulatory agencies considered staffing requirements with an aim to increase the numbers of nurses and other health care personnel working in hospitals and other settings. As the 1990s ended, a shortage of RNs emerged, and concern about poor staffing in hospitals continued ( ). It was in this environment that AB 394 was passed by the California legislature. Previous Republican governors had vetoed similar legislation, but union-friendly Democratic Governor Gray Davis signed AB 394, satisfying union efforts to pass minimum-ratio legislation. AB 394 charged the California DHS with determining specific unit-by-unit nurse/patient ratios. The DHS began an extensive effort to determine the new minimum nurse staffing ratios, with little research to guide them ( ; ; ). To help develop the proposed ratios, the DHS commissioned a study by researchers at the University of California, Davis ( ). It also received recommendations about the ratios from stakeholders, ranging from the California Hospital Association (CHA) proposal of a ratio of 1 licensed nurse per 10 patients in medical-surgical units and the California Nurses Association recommendation of 1 licensed nurse per 3 patients in medical-surgical units. The ratios established by DHS were between those recommended by the CHA and the unions, with a 1 : 6 ratio in medical-surgical units starting January 1, 2004, and a 1 : 5 ratio in medical-surgical units commencing in January 2005. Other units have higher minimum-ratio requirements. The minimum ratios do not replace the requirement that hospitals staff according to a patient classification system (PCS); if a hospital’s PCS indicates that higher staffing is needed, the hospital should staff accordingly. The implementation of California’s minimum nurse staffing ratio legislation led to legal challenges and state government efforts to expand RN education. It also drove increases in hospital nurse staffing and wages in California. Several studies have found that the ratios are linked to higher nurse satisfaction, but there is little evidence that the regulations improved patient outcomes. Some research has found that there may have been negative impacts on hospitals’ finances and ability to provide charity care. Two days before the ratios went into effect, the CHA filed a lawsuit arguing that the staffing ratios should not apply if a nurse takes a scheduled break or unscheduled restroom visit. The DHS contended that if the ratios were to have any meaning, they must be effective at all times. The judge hearing the case agreed with the DHS in a May 2004 ruling ( ). The second major legal challenge to the ratio regulations came from Governor Arnold Schwarzenegger, who sought to delay the implementation of the stricter ratio of one licensed nurse to five patients scheduled for January 2005 due to the severe shortage of licensed nurses ( ). The CHA filed suit against the DHS in December 2004 alleging that the emergency order had illegally bypassed the legislature ( ). In early March, a Superior Court judge tentatively ruled that the DHS had indeed not followed the law when issuing the emergency regulation ( ), and the judge’s decision was finalized in May 2005 ( , ; ). To assist hospitals in meeting the staffing ratio rules, both former Governor Davis and Governor Schwarzenegger dedicated funds to expanding nursing education and reducing attrition from nursing programs. Between 2004 to 2005 and 2009 to 2010, nursing graduations in California increased by 72%, reaching over 11,500 new RN graduates per year ( ). The inspection and enforcement mechanisms of the DHS are relatively weak. The DHS does not have the authority to impose fines or monetary penalties on hospitals that are found to violate the ratios, but instead requests and monitors plans submitted by hospitals to remedy the problem. However, other mechanisms do exist to ensure that hospitals adhere to the ratios. First, government payers such as Medicare and Medi-Cal (the state Medicaid program) require that hospitals meet all state and federal regulations and can deny payment to violators. Second, California’s cap on malpractice awards does not apply in cases of negligence, and a hospital could be deemed negligent if it consistently did not adhere to minimum nurse staffing regulations ( ). Third, unions draw public attention to hospitals that do not meet the staffing requirements, resulting in negative publicity for hospitals and increased scrutiny from DHS inspectors. Fourth, labor organizations that represent nurses have sought to incorporate staffing standards in their contract negotiations, with some success ( ; ). Several studies of all California hospitals have found that annual average numbers of RN productive hours and nurse staffing ratios in medical-surgical units increased markedly between 2001 and 2006 ( ; ; ; ; ; ). found that statewide average RN hours per patient day increased 16.2% from 1999 through 2006, to an average of 6.9 hours per patient day. Interviews conducted with hospital leaders by a research team at the University of California, San Francisco (UCSF) revealed that many chief nursing officers and other managers said they had hired nurses to meet the ratios, and most noted that it is challenging to adhere to the ratios at all times, including during scheduled breaks ( ). surveyed nearly 80,000 RNs in California, New Jersey, and Pennsylvania to learn their experiences with staffing, the work environment, and patient care. They found that nurse workloads, measured according to the average number of patients per shift, were lower in California than in New Jersey and Pennsylvania and that over 80% of California nurses reported that their assigned workloads were in compliance with the state’s regulation. There have been concerns that hospitals may have eliminated support staff positions because of the minimum licensed nurse staffing requirements ( ). Analyses of staffing data collected by the Collaborative Alliance for Nursing Outcomes (CALNOC) suggest that the substitution of licensed nurses for unlicensed staff may be widespread as the increase in RN staffing was much larger than the overall staffing increase among their hospitals ( ; ). In a series of qualitative interviews, some hospital leaders reported that they had laid off ancillary staff to use budgets to hire more RNs ( ), and the survey conducted by Aiken and colleagues found that nurses perceived reductions in LVN and aide use ( ). However, more recent analyses have measured only a slight decline in LVN staffing ( ; ; ) and aide staffing ( ; ). The California Hospital Association warned that strict minimum nurse/patient ratio requirements would force hospitals to reduce their services. To maintain the minimum ratios, hospitals might reschedule procedures, close selected units and beds, or shut their doors entirely. However, there have been few verified reports of the minimum nurse/patient ratios causing permanent closures of inpatient hospital units or beds. There is some indication that there was lower growth in the provision of uncompensated care services among hospitals on which the regulations had the greatest impact on staffing levels ( ). Since 1999, California hospitals have been financially buffeted by numerous factors, including changes in Medicare and Medicaid payment policy and requirements that hospital facilities meet seismic standards through retrofitting or new construction ( ). Thus, it is difficult to determine whether the staffing regulations had any discernable effect on hospital finances. Qualitative evidence reported that hospital CEOs absorbed the costs of the ratios by reducing other budget areas, and some hospitals were able to obtain higher insurance reimbursement rates to cover additional staff expenses ( ). However, one analysis found that hospital prices rose even more between 1999 and 2005 than could be explained by labor cost increases that resulted from the nurse staffing ratios alone ( ). In an analysis of hospital financial data, found no significant change in total annual labor costs for licensed nurses, total annual hospital costs, or hospital prices. used data from Medicare cost reports to explore whether changes in financial status differed between California hospitals that had higher versus lower preregulation staffing levels, and between California and other states. They found that relative to hospitals outside California, operating margins for California hospitals with lower preregulation staffing levels declined, and operating expenses increased significantly. In theory, when the demand for workers rises more rapidly than the supply, wages should rise. Two studies have examined whether growth in the hiring of RNs caused by the staffing regulations is linked to more rapid growth in RN wages. One study found that wage growth among urban RNs in California was as much as 12% higher than in other states ( ). A more recent analysis measured a 4.9% increase in RN wages between 2000 and 2007 with one dataset, and no increase at all with a different dataset ( ). Advocates of staffing ratio regulations link improved staffing to nurse satisfaction and argue that greater nurse satisfaction will reduce nurse turnover and lead to better patient outcomes ( ; ). An analysis of statewide nurse survey data found that there were significant improvements in overall job satisfaction among hospital-employed RNs between 2004 and 2006 ( ). Nurse satisfaction also increased with respect to the adequacy of RN staff, time for patient education, benefits, and clerical support. also found in their survey of nurses in three states that RNs in California were more satisfied with their working conditions. Nurses in California were significantly more likely to report that their workload was reasonable and allowed them to spend adequate time with patients and that they were able to take breaks during the workday. Nurses with lower workloads were significantly less likely to report that they received complaints from families, faced verbal abuse, were burned out, were dissatisfied, felt quality of care was poor, or were looking for new jobs. One of the main purposes of California’s minimum staffing legislation was to improve the quality of patient care. However, to date there is no convincing evidence that patient safety or the quality of care has improved. In the first paper published on this subject, rates of patient falls and hospital-acquired pressure ulcers reported to CALNOC between 2002 and 2004 were analyzed for 68 hospitals, and it was found that there was no statistically significant change that could be attributed to the ratios ( ). A follow-up study of data through 2006 confirmed these results ( ). These analyses had two main shortcomings: They included only a subset of California’s hospitals and the two outcomes examined might not be very sensitive to changes in licensed nurse staffing. Studies that examine whether licensed nurse staffing affects rates of hospital-acquired pressure ulcers and postoperative hip fractures from a patient fall have produced mixed findings ( ). Aiken and colleagues linked their survey data to secondary data on patient outcomes collected by state government agencies ( ) and found that in all three states studied, higher nurse staffing levels were associated with lower rates of 30-day inpatient mortality and failure-to-rescue. These relationships were stronger in California than in other states. However, this analysis cannot confirm that the staffing regulations directly caused changes in patient outcomes. Research based on a single year of data does not measure the effect of changes in policy or practice on changes in patient outcomes. Although the responses of nurses regarding the patient safety environment suggest that the lower workloads in California are associated with more positive nurse perceptions of patient safety, these perceptions may not lead to actual improvements in patient outcomes. It’s important to note that the analysis of patient outcomes in this study was limited to two outcomes. Several newer studies have used multiple years of statewide data and examined a wider variety of outcomes. For example, Spetz and colleagues examined OSHPD patient discharge data for all nonfederal, general acute care California hospitals from 1999 through 2006 but could not associate improvements in outcomes to the implementation of the ratios ( ). In a more rigorous analysis of OSHPD data from 2001 to 2006, found no association between changes in nurse staffing and changes in pressure ulcer rates or failure-to-rescue a patient after a complication. Using similar methods, examined six patient safety indicators using OSHPD data from 2000 to 2006 and found that growth in registered nurse staffing was associated with an improvement for only one outcome, mortality following a complication. They also analyzed whether the average length of stay declined among patients who experienced adverse events to explore the possibility that improved surveillance in better-staffed hospitals might reduce the severity of any complications. They found growth in staffing was significantly associated with reduced length of stay for only one patient safety indicator: select infections due to medical care. The most comprehensive analysis of the impact of California’s regulations on patient outcomes was published by . Using patient discharge data from California and 12 comparison states they examined whether differences in staffing changes between California and other states were associated with different patient outcome trajectories. Their analysis also considered differences between hospitals with high preregulation staffing as compared with low preregulation staffing. They found that failure-to-rescue following a complication decreased significantly in some California hospitals, and infections caused by medical care increased significantly in some California hospitals as compared with comparable hospitals in other states. There were no statistically significant changes in either respiratory failure or postoperative sepsis. Together, this research indicates that California’s regulations did not systematically improve the quality of patient care, although there remains a need for more research on this topic. The outcomes examined thus far have been relatively limited, and it is possible that patient care improvements will be found in other areas such as medication safety. It also is possible that changes in patient outcomes caused by the staffing ratios occur over a longer period of time. However, examining and interpreting data over a longer period of time will be complicated by the fact that many health systems and hospitals have established quality improvement programs in response to increased public attention to medical errors and patient outcomes. One remaining issue central to the debate about minimum nurse/patient ratios has yet to be addressed: What was the total cost of the ratio regulations? Any positive impact of minimum staffing ratios should be weighed against their cost ( ). As of 2014, these costs had not been accurately quantified. A careful accounting of the extent to which increases in nurse staffing were necessitated by the ratios, and the cost of any such increases, is necessary. Moreover, it is important to quantify the value of other investments hospitals might have made if they were not required to adhere to the staffing ratios. A hospital may have delayed implementation of a new infection-control system that would have reduced infection rates, and such opportunity costs should be included as part of the overall cost of the staffing regulations. The only federal regulation that directly referred to nurse staffing levels in hospitals at the time of writing is the 42 Code of Federal Regulations (42CFR 482.23[b]), which requires hospitals that participate in Medicare to have “adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed” ( ). In 2009, Sen. Barbara Boxer (D-CA) introduced S 1031, and Rep. Janice Schakowsky (D-IL) introduced H.R. 2273, both of which would have required that hospitals implement nurse-to-patient staffing plans and meet minimum RN nurse-to-patient ratios for specified patient care units. These bills did not pass, although the bills were reintroduced in 2011 and 2013. Some states have pursued their own staffing regulations. State regulations generally take one or more of three approaches: a requirement that hospitals develop and implement nurse staffing plans with direct input from nurses, requiring public disclosure of staffing levels, and/or establishment of fixed minimum staffing ratios. California is the only state to have implemented a law using this third strategy, although similar legislation has been proposed in other states including Illinois, Kentucky, Maryland, New Jersey, New York, Vermont, and West Virginia. Some states have opted to develop staffing regulations that offer hospitals more flexibility than fixed minimum staffing ratios. Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington have signed into law requirements that hospitals implement and enforce a written nurse staffing policy. In most of these states, the staffing policy must be developed by a committee that includes staff nurses. Rhode Island requires that hospitals submit a “core staffing plan” to the state department of health annually, with specific staffing for each patient care unit and each shift ( ). The third, and least binding, approach to nurse staffing regulation is to mandate reporting of staffing ratios to the public or to a regulatory agency. In New York, for example, facilities must make available to the public information about nurse staffing and patient outcomes. Specific adverse events, such as medication errors and decubitus ulcers, are considered reportable information under this law. Other states with public reporting requirements are Illinois, New Jersey, Rhode Island, and Vermont. New Jersey’s regulation mandates that hospitals post daily staffing information for each unit and shift and provide these data to state regulators, and in 2009, New York added a similar posting requirement to its regulations. Even without new legislation, hospitals are likely to continue to focus on nurse staffing improvements as the evidence suggests that nurse staffing is a good financial investment in quality improvement ( ). More research is needed, however, to determine whether the lack of measured benefit from California’s regulation is caused by limitations of prior research or indicative of an actual lack of impact. If California’s regulation can one day be shown to have improved patient outcomes at an acceptable cost, it will be easier for other states to follow in California’s footsteps. 1. It is not clear from the research conducted thus far whether California’s staffing regulations have improved patient outcomes. However, several studies have found that nurse satisfaction has improved and that nurses perceive that they are providing better care. Is improving nurse satisfaction a sufficient reason to establish this type of regulation? 2. Several studies have suggested that hospitals responded to the staffing regulations by reducing staffing of non-RN personnel. What might be the benefits and consequences of reducing non-RN staffing? 3. Are regulations that require staffing committees likely to effectively address concerns about inadequate nurse staffing? What about laws that require public reporting of staffing levels? Agency for Healthcare Research and Quality. . [AHRQ Publication No. 03-R203] Agency for Healthcare Research and Quality: Rockville, MD; 2005. Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, Seago JA, et al. Implications of the California nurse staffing mandate for other states. . 2010;45(4):904–921. Aiken LH, Sochalski J, Anderson GF. Downsizing the hospital nursing workforce. . 1996;15(4):88–92. American Nurses Association. . [Retrieved from] ; 2009. American Nurses Association. . [Retrieved from] ; 2013. Antwi YA, Gaynor M, Vogt WB. . [Retrieved from] ; 2009. Associated Press. . . 2014 [Retrieved from] . Benson, C. (2005a). Final ruling backs higher nurse ratio. , A5. Benson, C. (2005b). Judge orders launch of nurse staffing rule. , A4. Berestein, L. (2004). Industry group contends measure may hurt patients. , C3. Bolton LB, Aydin CE, Donaldson N, Brown DS, Sandhu M, Fridman M, et al. Mandated nurse staffing ratios in California: A comparison of staffing and nursing-sensitive outcomes pre- and post-regulation. . 2007;8(4):238–250. California Nurses Association. . California Nurses Association: Oakland, CA; 2009. Chapman S, Spetz J, Kaiser J, Seago JA, Dower C. How have mandated nurse staffing ratios impacted hospitals? Perspectives from California hospital leaders. . 2009;54(5):321–336. Conway PH, Konetzka RT, Zhu J, Volpp KG, Sochalski J. Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net. . 2008;3(3):103–199. Cook A. . [Unpublished doctoral dissertation] Carnegie Mellon University: Pittsburgh, PA; 2009. Cook A, Gaynor M, Stephens M Jr, Taylor L. The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California’s minimum staffing regulation. . 2012;31(2):340–348. Donaldson N, Bolton LB, Aydin C, Brown D, Elashoff J, Sandhu M. Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. . 2005;6(3):1–12. Donaldson N, Shapiro S. Impact of California mandated acute care hospital nurse staffing ratios: A literature synthesis. . 2011;11(3):184–201. Gledhill L. Governor loses to nurses in ruling: He illegally blocked law that set staffing ratios, judge says. . 2005 [A1]. Gordon R. Nurses pact ready for vote: Plan would raise pay, offer higher signing bonus. . 2005 [B4]. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nursing staffing and quality of patient care. . 2007;( ):1–115 [Retrieved from] . Kilborn, P. T. (1999). Current nursing shortage more serious than those of the past. , A14. Kravitz R, Sauve MJ, Hodge M, Romano PS, Maher M, Samuels S, et al. . University of California, Davis: Davis, CA; 2002. LaMar, A. (2005). Nurses protest delay of lower patient ratio, 1500 rally at Capitol to fight 3-year wait. , B2. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. . 2004;34(7–8):326–337. Mark B, Harless DW, Spetz J. California’s minimum nurse staffing legislation and nurses’ wages. . 2009;28(2):w326–w334. Mark B, Harless DW, Spetz J, Reiter KL, Pink GH. California’s minimum nurse staffing legislation: Results from a natural experiment. . 2012;48(2 pt1):435–454. Munnich E. The labor market effects of California’s minimum nurse staffing law. . 2013;23(8):935–950. Osterman, R. (2005). Hospitals accept nursing ratios. , D1. Public Policy Associates. . Michigan Nurses Association: Lansing, MI; 2004. Rapaport, L. (2004). State eases nurse-staffing law until 2008—Hospital closings and delays in patient care prompt move. , A1. Reiter KL, Harless DW, Pink GH, Mark B. Minimum nurse staffing legislation and the financial performance of California hospitals. . 2012;47(3 pt1):1030–1050. Reiter KL, Harless DW, Pink GH, Spetz J, Mark B. The effect of minimum nurse staffing legislation on uncompensated care provided by California hospitals. . 2011;67(6):694–706. Robertson K. New nurse law fails to cause emergency. . 2004;21(9):1. Rothberg MB, Abraham I, Lindenauer PK, Rose DN. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. . 2005;43(8):785–791. Salladay, R., & Chong, J.-R. (2005). Judge backs nurses over staffing. , B1. Spetz J. Hospital use of nursing personnel: Has there really been a decline? . 1998;28(3):20–27. Spetz J. What should we expect from California’s minimum nurse staffing legislation? . 2001;31(3):132–140. Spetz J. Nurse satisfaction and the implementation of minimum nurse staffing regulations. . 2008;9(1):15–21. Spetz J. . Board of Registered Nursing: Sacramento, California; 2013. Spetz J, Chapman S, Herrera C, Kaiser J, Seago JA, Dower C. . California HealthCare Foundation: Oakland, CA; 2009. Spetz J, Harless DW, Herrera C-N, Mark BA. Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. . 2013;70(4):380–399. Spetz J, Seago JA, Coffman J, Rosenoff E, O’Neil E. . California HealthCare Foundation: San Francisco; 2000. Unruh L, Fottler M. Patient turnover and nursing staff adequacy. . 2006;41(2):599–612. Wunderlich GS, Sloan FA, Davis CK. . National Academies Press: Washington, D.C.; 1996. American Nurses Association: Nurse Staffing Plans and Ratios. . National Nurses United: National Campaign for Safe RN-to-Patient Staffing Ratios. . Robert Wood Johnson Foundation: The Impact of Nurse Staffing on Hospital Quality. . . Alice Walker March 31, 2013 marked an important deadline in the implementation of landmark legislation, the Affordable Care Act (ACA) , also known as Obamacare. By that date those eligible to enroll for insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media attention, an estimated 8 million people signed on for coverage during open enrollment—the period between October 2012 and the deadline—exceeding the revised target of 6.5 million ( ). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s Health Insurance Program (known as CHIP) ( ). Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an assistant professor at Arizona State University College of Nursing, used her role as president of the Phoenix Chapter of the National Association of spanic Nurses to organize town hall meetings with Spanish-speaking state residents to explain the ACA and encourage enrollment among those with a high rate of un- or under-insurance. She also developed a training model in partnership with AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on the basic provisions of the ACA. Through many such initiatives, the United States reduced the number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by 2016 ( ). However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care when needed at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired outcomes we ought to have and too often damages instead of heals ( ). Despite spending more per person on health care than any other nation, a comparative report on health indicators by the shows that the United States performs worse than other nations on life expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and other indicators. In 1999, the Institute of Medicine (IOM) issued a report, , which estimated that health care errors in hospitals were the fifth leading cause of death in the U.S. ( ). By 2011, preventable health care errors were estimated to be the third-leading cause of death ( ; ). The ACA includes elements that can begin to create a high-performing health care system, one accountable for the provision of safe care, as well as improved clinical and financial outcomes. It aims to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses. For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission rates. It also provides funding for demonstration projects that improve “transitional care,” services that help patients and their family caregivers to make a smoother transition from hospital or nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part, on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of accountability across health care settings, with most using nurses for care coordination and transitional care providers ( ; ; ). Promoting health requires more than a high-performing health care system. First and foremost, health is created where people live, work, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code ( ). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic disparities persist ( ). Individual health and family health are severely compromised in communities where good education, nutritious foods, safe places to exercise, and well-paying jobs are scarce ( ). Creating a healthier nation requires that we address “upstream factors”; the broad range of issues, other than health care, that can undermine or promote health (also known as “social determinants of health” or “core determinants of health”) ( ). Upstream factors promoting health include safe environments, adequate housing, and economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. According to , the key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both in and outside of health care systems. Upstream factors have a large influence on the development and progression of illnesses ( ). The core determinants of health will be used to further elucidate and make concrete the wider, more comprehensive set of upstream factors that can improve the health of the nation by reducing disparities. depicts the core determinants of health developed by the Canadian Forces Health Services Group. Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An Evolution of Excellence. (From .) A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than those who are wealthy, with high costs in human and financial terms ( ). To date however, most of the focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once the individual has entered the health care system–despite the fact that for more than a decade research has established that most health care problems begin long before people seek medical care ( ). Thus, changing the paradigm requires knowledge about the political aspects of the social determinates of health and the broader core determinants. Political aspects of the social determinants of health appear in . • The health of individuals and populations is determined significantly by social factors. • The social determinants of health produce great inequities in health within and between societies. • The poor and disadvantaged experience worse health than the rich, have less access to care, and die younger in all societies. • The social determinants of health can be measured and described. • The measurement of the social determinants provides evidence that can serve as the basis for political action. • Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation. • Evidence of the effects of policies and programs on inequities can be measured and can provide data on the effectiveness of interventions. • Evidence regarding the social determinants of health is insufficient to bring about change on its own; political will combined with evidence offers the most powerful strategy to address the negative effects of the social determinants. Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T. Houweling, L. Jadue, and F. Florenza. The ACA begins to carve out a role for the health care system in addressing upstream factors. For example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive federal tax breaks. Hospitals must conduct a community health assessment, develop a community health improvement plan, and partner with others to implement it. This aligns with a growing emphasis on population health: the health of a group, whether defined by a common disease or health problem or by geographic or demographic characteristics ( ). Consider the 11th Street Family Health Services. Located in an underserved neighborhood in North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel University School of Nursing. She recognized that the leading health problems in the community were diabetes, obesity, heart failure, and depression. Working with a community advisory group, Gerrity realized that the health center had to address nutrition as an “upstream factor” that could improve the health of those living in the community. With no supermarket in the neighborhood until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She also created a community vegetable garden maintained by the local youth. And area residents were invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family Health Services is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities ( ). The ACA authorizes continued support for these centers, although the law does not mandate they be funded. Congress would have to appropriate funding for NMHCs but has not done so. (See for a more detailed discussion of NMHCs.) The ACA may not go far enough in shifting attention to the health of communities and populations. One approach gaining notice is that of “health in all policies,” the idea that policymakers consider the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing ( ; ). As health professionals who focus on the family and community context of the patients they serve, nurses can help to raise questions about the potential health impact of public policies. Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what type of health care, when, how, from whom, and at what cost. The study of health policy is an indispensable component of professional development in nursing, whether it is undertaken to advance a healthier society, promote a safer health care system, or support nursing’s ability to care for people with equity and skill. Just as Florence Nightingale understood that health policy held the key to improving the health of poor Londoners and the British military, so are today’s nurses needed to create compelling cases and actively influence better health policies at every level of governance. With national attention focused on how to transform health care in ways that produce better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide proactive and visionary leadership. Indeed, the landmark report, (2011), calls for nurses to be leaders in redesigning health care. But will nurses rise to this occasion? Health care opinion leaders in a 2010 poll identified two reasons nurses would fall short of influencing health care reform: too many nurses do not want to lead, and with over 120 national organizations, nursing often fails to present a united front ( ). As the largest health care profession, nursing has great potential power. Yet, similar to many professions, it has struggled to collaborate within its ranks or with other groups on pressing issues of health policy. The IOM report has provided a rallying point for nursing organizations to work together and engage other stakeholders to advance its recommendations. In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) first described the Triple Aim of a value-based health care system ( ): (1) improving population health, (2) improving the patient experience of care, and (3) reducing per capita costs. This framework aligns with the aims of the Affordable Care Act. The Triple Aim represents a balanced approach: by examining a health care delivery problem from all three dimensions, health care organizations and society can identify system problems and direct resources to activities that can have the greatest impact. Looking at each of these dimensions in isolation prevents organizations from discovering how a new objective, decreasing readmission rates to improve quality and reduce costs, for instance, could negatively impact the third goal of population health, as scarce community resources are directed to acute care transitions and unintentionally shifted away from prevention activities. Solutions must also be evaluated from these three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden their focus on acute and highly specialized care toward more integrated care, including primary and preventive care ( ). The identified these components of any approach seeking to achieve the Triple Aim: • A focus on individuals and families • A redesign of primary care services • Population health management • A cost-control platform • System integration and execution Note that these possess the goal of creating a high-performing health care system but do not focus on geographic communities or social determinants per se. However, these two concepts can be incorporated into the Triple Aim of improving the health of populations and reducing health care costs. The Triple Aim is easy to understand but challenging to implement beca
