october 10, 20071 f-6. pay for performance. are you ready? october 10, 2007 presented by: joy...
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October 10, 2007 1
F-6. Pay for Performance. Are You Ready?October 10, 2007
presented by: Joy Morrow, RN, PhD., Senior Clinical ConsultantHansen, Hunter, & Company, P.C.,
Beaverton, Oregon1-800-547-3159
October 10, 2007 2
Long Term Care Culture Changes
1990 – OBRA, MDS assessment tool, emphasis on social model as well as clinical assessment
1998 – PPS, Medicare skilled service payments based on acuity, clinical assessment
October 10, 2007 3
2006 And On
Value based purchasing for Medicare (& Medicaid) services, Pay for Performance model introduced, health care service payments based on quality and efficiency (cost)
October 10, 2007 4
Research
Evidence-based studies It is about outcomes It is about cost It is about how the two meet for quality of care
October 10, 2007 5
Secretary Leavitt Reports to Congress
Improvement has occurred on clinical quality measures
Need for more improvement to succeed in promoting broader, more rapid improvement that results in high levels of quality for Medicare beneficiaries and efficient use of Medicare resources
October 10, 2007 6
FOUR STRATEGIES:If Adopted by Providers Can Lead To High Performance
Measurement & reporting of quality Adoption & use of health information
technology (“more computerized records”) Redesign of care processes (“treatment
protocols, screenings, disease management, follow up, etc.)
Change in organizational culture & management
October 10, 2007 7
CMSs Quality Improvement Roadmap
Work through partnerships: HHS, other Fed & state agencies, health professionals, etc.
Publish quality measures & info to beneficiary, purchaser, professional, provider, others
Pay to support providers in doing the right thing; improving quality, avoiding unnecessary costs, promoting competition to improve quality
October 10, 2007 8
Improvement Map (cont)
Assist practitioners & providers in taking the necessary steps to make care more effective & less costly, incl. use of electronic health systems
CMS will become active partner in creating & using evidence of healthcare technologies to bring innovations to pts more rapidly, & help Drs. & pts use txs Feds pay more effectively
October 10, 2007 9
CMSs Goals
Through quality improvement initiatives Will modernize Medicare through pay for
performance and Competitive bidding programs
October 10, 2007 10
Pay for Performance (P4P)
Value based purchasing Quality based purchasing Performance based health care service
purchasing
October 10, 2007 11
How does cost of care combine with positive outcomes?
Through payment methods (i.e. pay for performance) & other incentives to obtain patient focused high quality care at the most reasonable cost
October 10, 2007 12
CMS believes that States are interested in…
Ways to improve quality of care in flexible programs that control costs & provide value for dollars spent and that
Payments are directed toward care that will improve health status of citizens
October 10, 2007 13
Pay for Performance is one method of value based, quality based purchasing
Incentive payments will be made to facilities who meet certain criteria based on quality measures from several sources
October 10, 2007 14
How is this Pilot Program Funded?
The pilot requires budget neutrality or cost effectiveness (“savings”)
Funding will come from reduced avoidable hospitalizations
October 10, 2007 15
Performance Measures/Quality Measures
Critical to the process of assessing improvements in quality & providing info to consumers
Nursing Homes were one of the first health care providers to be required to implement/use quality measures
October 10, 2007 16
Who Is Involved in Pay for Performance?
Hospitals Physician office practices/Ambulatory care Home Health Nursing Homes Medicare B: PT & OT Dialysis providers And more
October 10, 2007 17
CMS Describes the QIO Program
Substantial contribution to efficiency of resource use in Medicare
Program will increase focus in areas where their costs can be substantially offset by quality improvements that increase efficiency
October 10, 2007 18
QIO Program Contracting for Projects to Develop Evidence Base for Improving Quality & Efficiency
Preventing hospital admission for patients in nursing homes
Improving transitions of care for patients moving across settings
Measuring & improving palliative & hospice care
Improving quality & efficiency of care for pts w/multiple chronic illnesses
October 10, 2007 19
QIO Nursing Home Campaign Will Assess These Measurable Goals
Reducing high risk pressure ulcers Reducing use of daily restraints Improving pain management in long term &
short term, post acute residents Establishing individual targets for improving
quality Assessing res & family satisfaction w/quality
of care
October 10, 2007 20
Nursing Home Campaign (cont)
Increasing staff retention Improving consistent assignment of nursing
home staff, so res regularly receive care from same care givers
THE ABOVE MEASURES ARE IN ADDITION TO THE QIO PROGRAM AS IT HAS BEEN IN THE PAST
October 10, 2007 21
QIO Scope of Work Measures (subtasks)
Clinical Measures: Restraints, Pressure Ulcers, Pain, Depressive Symptoms
Non-clinical Measures: Staff retention, Resident satisfaction, Staff turnover, Target-setting on clinical measures, Process changes on clinical measures
October 10, 2007 22
Other Pay for Performance Programs
Improvement in patients with certain chronic diseases
Pt & OT therapy outcomes for Med B Certain hospital clinical conditions Post acute payment reform demonstration Medicaid P4P
October 10, 2007 23
Post Acute Payment (PAC) Reform Demonstration
Scheduled to start in April 2008 Diagnoses or diagnostic conditions specified
by Secretary Leavitt would require a comprehensive assessment at hospital discharge to help determine appropriate post acute care placement
October 10, 2007 24
Post Acute Care Demonstration (cont)
The Post Acute Care placement based on pt needs & pt clinical characteristics
Data on fixed & variable costs for each pt & on care outcomes would be gathered
Standardized assessment instrument to measure functional status & other factors during tx & at discharge across PAC settings
October 10, 2007 25
NURSING HOMES: Pay for Performance
Quality Measures from MDS Sec W (immunizations) Surveys Staffing levels Avoidable hospitalizations
October 10, 2007 26
Recommended Measures by Abt Associates Inc. (demonstration design)
Nursing home staffing Rate of potentially avoidable hospitalizations MDS-based resident outcome measures Outcomes from state survey inspections
October 10, 2007 27
How will Performance be measured for Nursing Homes?
Answers to the MDS including:1. Subset of MDS driven quality measure
(nursing home compare)2. Resident immunization rates (Sec W) Outcomes from surveys Staffing levels (licensed and certified
nursing assistant hrs per res day) & rewards for high staff retention &/or low turnover
October 10, 2007 28
Performance Measures for Nursing Homes (cont)
Potentially avoidable hospitalizations, both long and short stay
October 10, 2007 29
Avoidable Hospitalizations; Short Stay Residents
Potentially avoidable hospitalizations: short stay residents, % of short stay res with a hospitalization w/in 30 days of admit or 7 days of discharge if length of stay is less than 23 days for a potentially avoidable hospitalization
Source of info: Medical record
October 10, 2007 30
Potential Problems to Consider
Could be “bad outcome gaming”; not sending someone to hospital
Need to consider patient request to go to hospital
How do we deal with families that insist on transfer?
Need to consider code status
October 10, 2007 31
Who Is Reviewing Record?
What is the criteria for determining that a hospitalization was potentially avoidable?
What does documentation say? Nurses notes Physician notes Lab reports Assessments Etc.
October 10, 2007 32
Avoidable Hospitalization: Long Stay Resident
Source of information: Medical Record
October 10, 2007 33
Recommended Risk Adjustment for Potentially Avoidable Hospitalizations
Age ADL score Bedfast Cognitive Performance Scale Congestive Heart Failure Do Not Resuscitate Dysphagia
October 10, 2007 34
Risk Adjustment (cont)
Feeding tube present Hypertension with complications Renal failure Requires assistance to eat Respiratory disease
October 10, 2007 35
DISCUSSION
October 10, 2007 36
Specific MDS questions that are calculated
ADL decline Pain Physical restraints Urinary Tract Infections Pressure sores, high risk, low risk Worsening of depression or anxiety Bedfast
October 10, 2007 37
Specific MDS info (cont)
Indwelling catheter Incontinence, low risk Mobility decline (locomotion, self
performance) Weight loss Delirium and/or pain on post acute residents Section W
October 10, 2007 38
Other Measures/Survey Focus Issues
Process measures Resident satisfaction Quality of life measures New measures will be added as new data
becomes available
October 10, 2007 39
Possible Process Issues
Treatments, timing, protocols for wound care Treatment, timing, results for pain
management Decisions, interventions for acute symptoms Incident, complaint management Care plans, follow up
October 10, 2007 40
Per CMS, Information Re: Nursing Home Process Issues Will Come From:
Survey QIO interaction/feedback
October 10, 2007 41
Possible Post Acute Care Process for Nursing Homes
How quickly did RN assess and intervene Was care plan implemented appropriately Were current orders carried out Was physician notified and new orders
received and implemented Was documentation appropriate Were skilled services performed within the
facility (i.e. O2, lab work, IVs, wound tx, etc.)
October 10, 2007 42
Resident Satisfaction/Survey
Interviews with resident Interviews with family Interviews with significant other Interviews with legal representative
October 10, 2007 43
Quality of Life
Individualized activities Resident specific activity preferences Consistent direct care giver Food preferences What is most important to this specific
resident? Cognitively impaired/specific issues
October 10, 2007 44
Guide to Quality Measures
There is a compendium of all of the current quality measure throughout all health care delivery systems
October 10, 2007 45
General Categories: Compendium of Quality Measures
Access/children Acute Myocardial Infarction: ASA given, Ace
inhibitor given, Smoking cessation info, beta blockers ordered, thrombolytic agent w/in 30 mins of hosp arrival, time to pericutaneous coronary intervention is 120 mins or less, death w/in 30 days
Ambulatory care: hospitalization rate for all conditions, acute & chronic, children
October 10, 2007 46
Compendium (cont.)
Asthma: meds in ER & disch. w/steroids, medical record management, pharmacologic therapy management, hospital readmit rate
Osteoarthritis: diagnoses, pain management (incl. risk factors), exercise education
Hospital discharge process Children with special needs % of pts who return to ER w/in 7 days
October 10, 2007 47
Compendium (cont)
Coronary artery disease: artery graft pts who have bypass surgery, % of pts w/prior MI who were prescribed beta blockers, % pf pts who had lipid profile, % of pts on lipid lowering meds, cholesterol levels post cardiac event, % of pts w/diabetes &/or vascular disease & on ASA
October 10, 2007 48
Compendium (cont.)
Dental Depression: screening, med management,
length of tx, follow up, suicide risk, & other Diabetes: lab work & results incl. lipid
management, blood pressure management, retinol exams, foot exams, neuropathy monitoring, ASA therapy, pt management, smoking cessation, flu vaccine, hosp admits, amputations
October 10, 2007 49
Compendium (cont)
Efficiency: (chronic conditions, diabetes, cardiac condition, asthma, COPD, uncomplicated hypertension, ER discharge instructions)
End Stage Renal Disease: dialysis manage-ment, fistula issues, catheters, pts w/grafts, lab work & management, survival rate
October 10, 2007 50
Compendium (cont.)
Heart failure: detailed discharge instructions from hospital stay, left ventricular function assessment, med management, smoking cessation info, weight recorded, mortality w/in 30 days
HIV/AIDS: med mngmt, pt mngmnt, lab work, screenings, vaccinations, other
October 10, 2007 51
Compendium (cont)
Home health: improvement in ambulation, bathing, management of meds, pain management, dyspnea, urinary incontinence, hospitalizations, discharges from home health
Hypertension: blood pressure management & control
ICU care: stress ulcer prophylaxis, DVTs, length of stay
October 10, 2007 52
Compendium (cont.)
Infection: hospital; central lines, UTIs, Language/demand for interpreter Medication management: allergies,
therapeutic monitoring, geriatric med knowledge/management
Mental Health: children, general, #s of pts, & ADHD w/meds
Neo-natal Care
October 10, 2007 53
Compendium (cont) NURSING HOME
ADL decline: incidence, source; MDS Pain: prevalence, prevalence, source; MDS Physical restraints: prevalence, source; MDS UTIs, prevalence: source; MDS Pressure sores: High and low risk,
prevalence, source; MDS Worsening depression or anxiety:
prevalence, source; MDS
October 10, 2007 54
Prevalence vs. Incidence
Prevalence – a measurement of residents with a particular condition (quality measure) at one point in time
Incidence – The frequency of new occurrence of a particular QM condition over a period of time. The result of a comparison of two points in time (comparing info from two MDSs)
October 10, 2007 55
Compendium (cont) NURSING HOMES
Bedfast: prevalence, source; MDS Indwelling catheters: prevalence,source;MDS Incontinence,low risk:prevalence,srce;MDS Mobility decline, locomotion self performance
decline: prevalence, source; MDS Wt loss: (more than 5 % in 30 days or 10 %
in 6 mos, incidence, source; MDS Delirium: post acute pts,prvl,source; MDS
October 10, 2007 56
Compendium (cont) NURSING HOMES
Pain: post acute res,prevalence,source;MDS Pressure sores: post acute res,prvl,src;MDS Staffing: RNs, hrs per pt day,source; payroll
data Staffing: Total nursing (RN, LPN, aides) hrs
per res day, source; payroll data Turnover %: overall turnover % for nursing
staff, source; payroll data
October 10, 2007 57
Compendium (cont) NURSING HOMES
Satisfaction: Res experience of care in nursing home, source; survey
Potential avoidable hospitalizations: long stay res, source: medical record
October 10, 2007 58
Compendium (cont) NURSING HOMES
Potentially avoidable hospitalizations: short stay residents, % of short stay res with a hospitalization w/in 30 days of admit or 7 days of discharge if length of stay is less than 23 days for a potentially avoidable hospitalization
Source: Medical record
October 10, 2007 59
Compendium (cont)
Nursing sensitive: American Nurses Assoc. & JCAHO will look at pressure ulcers, nursing hrs per pt day, hrs of productive work by nursing staff w/direct care responsibilities, death among surgical pts (failure to rescue), % of pts w/hosp acquired pressure ulcers on dy of prevalence study, prevalence of restraints, on day of study
October 10, 2007 60
Compendium (cont)
Obesity: documentation in record Obstetrics: c.sections, live births, deaths,
perineal lacerations Patient Safety: hospitals, falls, ER pts leaving
AMA or w/out being seen, computerized physician orders, numerous hospital untoward occurrences & responses.
October 10, 2007 61
Compendium (cont.)
Pneumonia: tx in hosp Prenatal care: ambulatory care & hosp Prevention: influenza & pneumonia vaccine,
cancer screenings, smoking cessation, Chlamydia screening, services for children, ambulatory care setting
October 10, 2007 62
Compendium (cont.)
Respiratory: ER care & hosp pediatric care Satisfaction: hosp, health plan, ambulatory
care Sickle Cell Anemia: hosp readmission Surgical infection prevention: hosp
October 10, 2007 63
What Should We Do To Get Ready?
Knowledgeable MDS nurses are essential:
a. For accurate MDS completion
b. Regulatory compliance
c. Quality measure/quality indicator accuracy
d. Appropriate reimbursement
October 10, 2007 64
Competent RNs (& LPNs) to Perform Skilled Nursing Services
RNs who accurately assess RNs with critical thinking skills Licensed nurses who professionally
document Licensed nurses who can perform skilled
care: IVs, respiratory care, wound care, catheterizations, blood draws, etc.
Continuing skills education needed
October 10, 2007 65
Essential & Accurate Policies & Procedures
Have only the P & Ps you need Have P & Ps in place that assure conformity
w/federal regs re: immunizations Review your state regs on eating assistants
and all issues of res nutrition Review P & Ps for accidents and follow up Review & enhance end of life P & Ps Review abuse investigation P & Ps
October 10, 2007 66
Embrace Methods to Enhance Consumer Satisfaction
Designate best staff w/excellent communication & listening skills to handle res & family issues
Take time to build res & family relationships to ensure open dialog re: services offered & what constitutes reasonable & necessary hospitalization
Build consumer confidence in clinical staff
October 10, 2007 67
Professional Communication w/Res & Families
Educate and re-educate RNs and LPNs regarding how to communicate clinical information to residents and family
Educate all staff regarding what info they may share, how to refer to another staff person, etc.
October 10, 2007 68
Resident/Family Satisfaction Survey
Overall assessment Activities Environment (appearance, noise, odor,
home-like, etc.) Food Autonomy/privacy Clinical care & tx (physician & nurse)
October 10, 2007 69
Res Satisfaction (cont)
Personal care (aides) Staff interaction (clinical and non-clinical)
October 10, 2007 70
Know Your Reports
Aspen (Federal complaint tracking system) Oscar (which now includes payroll data) Complaints, internal and reported Complaint review and resolution process Incident tracking and resolutions Survey Etc.
October 10, 2007 71
Work On Staff Retention
Be creative in examining issues that enhance longevity
Establish a Registered Nurse/LPN focus group
Establish a Certified Nursing Assistant focus group
October 10, 2007 72
Consumer Satisfaction
Listen to individual consumer perceptions of quality
Such as, food, types of activities, friendly staff importance, consistent care giver importance, idiosyncrasies that can be accommodated
Handle complaints efficiently, effectively. Resolve issues.
October 10, 2007 73
Infection Control
Review infection control management Educate & re-educate staff re: infection
transmission and hand washing. Consider anti-bacterial gel dispensers
Improve systems UTIs, wound infections, & other facility
acquired infections may translate to avoidable hospitalizations
October 10, 2007 74
Pressure Ulcers
Emphasize importance of immediate identification and treatment of pressure issues
Have highly competent wound specialist on staff (w/one back up) who knows latest & best treatments
Have standing orders/protocols approved by medical director and primary physicians
October 10, 2007 75
Pressure Ulcers/Wound Care (cont.)
Continually assess and modify treatment as indicated
Wound nurse could be DON, Asst. DON, staff development nurse, anyone who is passionate about wound care. Does not have to be dedicated person in small facility or a wound consultant. On your staff is better.
October 10, 2007 76
Cognitively Impaired
Improve your programs Consider vocation boxes More music, color, and touch for severely
impaired
October 10, 2007 77
We Must Improve Our Documentation
Consider having documentation “guru” If incident occurs or a re-hospitalization is
considered, have “guru” assist in profess- ional appropriate documentation
Document sound clinical reasons for re-hospitalization
Educate/re-educate on accurate, professional documentation
October 10, 2007 78
Documentation Also Includes
An accurate assessment A care plan that is individualized Follow up and updating of the care plan Use critical thinking as you document
October 10, 2007 79
Surveys (Current Emphasis)
Will look at Res Satisfaction Will look at unnecessary drugs, pharmacy
issues, pharmacy reviews
October 10, 2007 80
Staffing
Know your actual daily staffing ratios Recommend RN staffing on post acute units More research details:- Very lg difference in RN staffing levels
between hosp based and free standing nursing homes
- Abt recommendation focused only on RN staffing
October 10, 2007 81
Hospital Based vs. Freestanding Nursing Homes
Median RN hrs per res day .75 for hosp based and .25 for free standing
75th percentile of RN hrs per res day was 1.76 for hosp based & .39 for free standing
10% of hosp based had 2.77 or more RN hrs per res day & 10 % of free standing had .56 or more RN hrs per res day
October 10, 2007 82
Details on Hospitalization Research
Nursing Homes with staffed with more RNs have less hospital readmissions
Nursing Homes with LPN staffing have more hospital readmissions
RN staffing for post acute care seems to make a difference
October 10, 2007 83
Hospitalization Research (cont)
Nursing Homes with more staff (esp. more RNs), more physicians available, physician extenders, nurse aide training, and less RN turnover had fewer hospitalizations
(Median RN hrs
October 10, 2007 84
Quality of Life
Activities Restraints; Is it possible to get to zero? Pain management Incontinence Food What does the res really care about? Almost everything relates to quality of life
October 10, 2007 85
Activities:Detail; Cognitively Impaired
Mild to moderate cognitive impairment: a. File cabinet with junk mail for homicide
detective, business executiveb. Homemaker stuff, laundry (we know this)c. Vocational boxes; demographic, i.e.
forestry, military, etc.d. Do generic ones & have families help create
individualized ones if needed
October 10, 2007 86
Activities (cont)
e. “Coffee Klatches”; “beer” and cards or sports, cocktail parties (time warped back to normal conversation)
f. Food – variety is not as important as individual pattern (peach pie with unwhipped whip cream)
g. Pot lucks, picnics, etc.
October 10, 2007 87
Activities (cont.)
h. Historic preference is good but remember that he/she could change their mind
i. “Garage sales” – room personalization
j. Restorative programs = one on one time, touch, mobility, etc.
October 10, 2007 88
Incontinence
Take resident to bathroom!!! Respond when resident calls out Team care for incontinence & to prevent it Know resident habits and take them to BR or
commode before urgent crisis Peri-care!!!! Odor abatement- BR doors closed, odor
neutralizers, laundry handling
October 10, 2007 89
Skilled Assessments: Sometimes Overlooked in Long Term Care
Lung issues: auscultation, deep breathing, turning, coughing, O2 Sats
Heart issues: B/P, pedal pulses, SOB assessment, pulse, and respiration
Two part assessments: assessment with and without activity
Critical thinking Other
October 10, 2007 90
POTENTIALLLY AVOIDABLE HOSPITALIZATIONS
Nurses must assess using critical thinking skills
May need to require second staff opinion when deciding if someone should go to hospital
Again, accurate professional documentation is essential
October 10, 2007 91
Ambulatory Care Sensitive Conditions
Conditions that are thought to not need hospitalization if appropriately treated in outpatient setting; such as:
- Congestive heart failure- Chronic Obstructive Pulmonary Disease- Urinary Tract Infection- Pneumonia
October 10, 2007 92
Ambulatory Care Conditions (cont)
Dehydration Diabetes Other
October 10, 2007 93
Breakdown of Percentages Recommended for Nursing Home Performance Scores
Staffing: 30 % Potentially avoidable hospitalizations: 30 % MDS based outcomes: 20 % Survey Deficiencies: 20 %
October 10, 2007 94
Other Potential Performance Measures
End of life care Resident perspectives on their nursing home
care (satisfaction) Medication errors Use of electronic medical records Whether home collects & monitors res care
experience & uses data
October 10, 2007 95
Potential Performance Measures (cont)
Nursing home staff immunizations Screening & tx of pain & depression Short-stay quality measure based on disch to
community Presence & role of medical director
October 10, 2007 96
Pay for Performance: Now & “Then”
Surveyors looking at issues in a new way QIOs looking at issues thru P4P “eyes” Medical record reviews including more than
“reasonable & necessary” evaluations Complaint investigations may change some Increased focus on MDS accuracy Other
October 10, 2007 97
Pay for Performance Now & “Then” (cont)
Medicare Veteran’s health care Long Term Care Insurance HMO co-pay Etc.
October 10, 2007 98
Seven States Have Developed P4P Plans For Medicaid Physician Services
Arizona Connecticut Idaho Massachusetts Missouri Ohio West Virginia
October 10, 2007 99
Medicare Physician Group Practices (P4P) Examples
Chronic Disease Management: diabetes and heart failure
-High cost/high risk patient management
-Transition management Expanding palliative & hospice care
October 10, 2007 100
Physician Group Practices P4P (cont)
Modify physician practice patterns & behavior:
- Encourage physicians to consider health of panel of pts rather than individual pts
- Delegation: physician extenders Information technology
October 10, 2007 101
Everett, Washington Physician Clinic
Project: Improve care delivery for seniors
a. Robust (more healthy) seniors – generally benefit from enhanced access to care; appropriate enrollment in disease manage-ment services for diabetes, congestive heart failure, coronary artery disease, & hyper-tension; & appropriate delivery of preventative services
October 10, 2007 102
Everett (cont)
b. Pre-frail seniors – generally do not utilize health care resources in optimal ways; it is believed they can benefit from improved discharge planning to reduce ER & hosp use
C. Frail seniors – often utilize high-cost hosp & SNF care; it is believed they can benefit from improved access to palliative care (to relieve suffering) & earlier hospice facility utilization when appropriate
October 10, 2007 103
University of Michigan Project
Care Management & Disease Management- Enhance communication between providers,
improve pt compliance, self-management, & access to necessary services
- Transitional care to reduce readmissions & “medical home” care to reduce readmissions
October 10, 2007 104
Michigan Project (cont)
Transition management:- Timely appointment scheduling, improve
availability of pt contact info, provide appropriate discharge counseling, reduce social barriers (transportation to appts, cost of meds), provide home care; also post discharge calls w/in 24 hrs of hosp disch
October 10, 2007 105
Michigan Project (cont)
“Medical Home”- Reducing first admissions, avoiding hosp
admissions- Vulnerable elderly, dual eligibles w/mental
health & social probs, end-stage renal disease
- Visiting nurse, pt education, self manage-ment support, advanced disease support
October 10, 2007 106
Medicaid Nursing Home P4P Programs
Iowa currently has nursing P4P program Kansas, Minnesota, Texas, Vermont have
either studied or tested the concepts in their states
October 10, 2007 107
F-6. Pay for Performance. Are You Ready?
MORE QUESTIONS AND DISCUSSION
Joy Morrow, RN, PhD [email protected]: 503-701-9155