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Retail Health Workforce


Strategy Think Tank:
Creating Effective Experiences for
Future Retail Health Clinicians

Tine Hansen-Turton, MGA, JD, FCPP, FAAN


Executive Director,
Convenient Care Association

Kelly Thompson, JD
Law and Policy Manager,
National Nurse-Led Care Consortium

CCA Provider Workforce Committee


Paul Bennie, RediClinic
Andrea Preisinger, RediClinic
Peter Goldbach, Health Dialog
Kristene Diggins, CVS MinuteClinic
Angela Patterson, CVS MinuteClinic
Frank Manole, CVS MinuteClinic
Susan Ferbet, Healthcare Clinics at Walgreens
Sandra Ryan, Walmart Care Clinics
Meggen Brown, The Little Clinic
Cathleen McKnight, The Little Clinic
Marilyn Wideman, Rush University
Peter Nordeen, FastCare
Nate Bronstein, CCA
Cheryl Fattibene, CCA
Tine Hansen-Turton, CCA

August 2017
Table of Contents
____________________________________________________________

Introduction…………………………………....………………………...... 3

Key Areas of Discussion……………………….….........…….………. 5

Recommendations…………………………………………………………10

Conclusion…………………………………………………………………... 13

Convenient Care Association | Report: Retail Health Workforce Strategy Think Tank | P. 2
Introduction
____________________________________________________________

On July 20, 2017, the Convenient Care Association (CCA) and its Provider Workforce Committee
convened expert stakeholders in Orlando, Florida for the “Retail Health Workforce Strategy
Think Tank” (“Think Tank”), a facilitated group discussion designed to identify methods to
strengthen the partnership between advanced practice nursing and physician assistant
programs and retail health, and ultimately to develop and strengthen the provider workforce.
The Think Tank featured a panel of experts representing the National Organization of Nurse
Practitioner Faculties (NONPF), American Association of Nurse Practitioners (AANP), American
Academy of Physician Assistants (AAPA), the National Nurse-Led Care Consortium (NNCC), and
CCA. Think Tank participants included providers, educators and stakeholders throughout the
retail-based convenient care industry. The overall objectives of the Think Tank were to
collectively identify methods to foster growth and opportunity for providers and the convenient
care industry, including innovative ways to educate advanced practice nurses and physician
assistants about retail-based health care, and to use retail-based convenient care clinics as both
clinical training sites and venues for employment.

The Think Tank built upon the conversation and recommendations arising from a Think Tank
convened a year prior, also hosted by CCA. The 2016 Think Tank brought together international
nursing experts, graduate nursing faculty, and clinic operators to commence important dialogue
about effectively preparing students to practice in retail health and advancing the retail health
industry. The objectives from that discussion were to explore core clinical competencies,
understand the gaps in education and preparedness of graduates, and identify collaborative
opportunities to expand awareness of the industry among clinical educators. As a key
takeaway, schools of nursing were encouraged to develop clinical opportunities in retail health,
and to encourage clinics to develop post-graduate programs to improve onboarding. Building
on the 2016 conversation, the 2017 Think Tank broadened its reach to obtain input from
physician assistant programs. The updated discussion focused on needs for improvement in
new graduate readiness to practice in retail health, partnering educators and clinicians, and
industry policy priorities and strategies.

Retail Health Industry Overview


Retail-based convenient care clinics (“CCCs”), often referred to as retail clinics, are usually
located in retail locations such as pharmacies and drug stores, supermarkets, big box retailers
and other high-traffic retail settings with pharmacies. CCCs are known for providing easily
accessible, affordable, quality healthcare to consumers who typically would have to wait hours,
days or even weeks for basic primary healthcare. The clinics also serve as an alternative for
many people who would otherwise seek costly, time-consuming emergency room care for
illnesses that could have been prevented had healthcare services been as readily accessible as
they currently are in retail locations. CCCs have provided more than 40 million basic primary

Convenient Care Association | Report: Retail Health Workforce Strategy Think Tank | P. 3
healthcare patient visits to date.1 As of 2015, there are more than 234,000 practicing NPs and
101,000 practicing PAs, with over 5,000 NPs and PAs working in the retail health industry. It is
expected that the need for more practitioners will grow as the industry evolves and expands.2

Research has identified retail clinics as the lowest cost unsubsidized provider of healthcare.
Retail clinics prove to be remarkably geographically accessible, as nearly 40 percent of the
urban U.S. population lives within ten minutes of a clinic.3 Notably, an estimated 50 to 60
percent of retail clinic patients report that they do not have a primary care provider.4 In that
sense, clinics often serve as a point of entry to health systems for patients.

Currently, many retail clinics provide a variety of services and patient education opportunities.
Clinics have increased their education offerings and wellness services beyond acute ailments,
including screenings, tobacco cessation support, mental health treatment, and chronic disease
management, as well as preventative services such as flu shots and immunizations. For
example, retail health is credited with increasing rates of patients receiving flu shots from
32.2% in 2003 to 40.3% in 2013.5 The ability of clinics to reach previously uninvolved patients
and the increasing breadth of provided services has attracted healthcare system partners.
Today, more than 240 health systems are actively involved with retail clinics.

Think Tank Objectives


The objectives of the intensive Think Tank discussion were as follows:

Define clinical and administrative competencies, standards and best practices of retail
health providers.

Explore ways to improve identified educational gaps and to ensure new graduate
readiness for the retail health industry.

Identify opportunities for retail health workforce experts to help schools prepare
students for successful retail healthcare careers.

Develop recommendations for strategic collaboration between advanced practice


provider education programs and retail health.

1
“Convenient Care Clinics: Addressing Unmet Need.” http://www.ccaclinics.org/.
2
Riff J, Ryan S, Hansen-Turton T. Convenient Care Clinics: The Essential Guide to Retail Clinics for Clinicians,
Managers and Educators. Springer Publishing; 2013.
3
Pollack CE, Armstrong K. The geographic accessibility of retail clinics for underserved populations. Arch Intern
Med 2009;169:945–9.
4
Mehrotra, A., & Lave, J. (2012). Visits to Retail Clinics Grew Fourfold From 2007 To
2009, Although Their Share of Overall Outpatient Visits Remain Low. Health Affairs, 31.
5
Heath, Sara. PatientEngagementHIT. “Retail Clinic Access Bumps Patients Receiving Flu Shots Rate.” August 15,
2017. https://patientengagementhit.com/news/retail-clinic-access-bumps-patients-receiving-flu-shots-rate

Convenient Care Association | Report: Retail Health Workforce Strategy Think Tank | P. 4
Key Areas of Discussion
____________________________________________________________
The following topics were the focus of this year’s Think Tank discussion, and expand upon
central themes of the preceding Think Tank.

Identify Competencies of Retail Health Providers


Retail health leaders have developed a working list of competencies that retail health providers
must possess to be effective and competent providers. Leaders have identified the following as
core competencies of retail health providers:
1) Patient-centered quality and safety. Providers employ a holistic, patient centric
focus, and commit to continuity of care in support of the patient-centered medical
neighborhood. They adhere to evidence-based practice, and use evidence to inform
process improvement and service scope. They are able to assess and determine the
most likely differential diagnosis, and to assess the most appropriate level of care for
safe and high-quality treatment.

2) Customer service excellence. Providers emphasize customer service, focus on the


patient, and create a warm and welcoming environment. Providers communicate and
influence effectively, adjust communication style based on patient needs, and support
customer knowledge and awareness of cost and value of care. They seek to increase
patient engagement and satisfaction through integration of feedback from patients.

3) Healthcare environment management. Providers continually reprioritize


throughout the day to fulfill patient and business needs. They effectively manage
clinical and non-clinical duties, demands of clinic operations, patients in the waiting
room, and incoming phone calls while maintaining focus on providing high quality care
to each patient in the exam room. Providers quickly adapt to new models of clinic
efficiency that benefit patient care, and are proficient with information management
and technology.

4) Business acumen. Providers demonstrate capability and accountability in managing


a profitable business. This includes, but is not limited to, management of budgets,
payroll, inventory, and appropriate collection of money and/or billing of insurance.
They possess a broad knowledge of payor coverage and healthcare finance. They drive
business results by connecting day-to-day activity to achievement of overall business
goals and marketing to the community.

5) Clinical practice decision-making autonomy. As retail health providers typically


work independently, they must be self-motivated, able to prioritize, think critically to
solve problems, take initiative, and advocate for their patients and their business both
externally and within the store. Autonomy is evidenced by participation in
professional groups, representation on committees within their organization, and/or

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having prior roles such as charge nurse/house supervisor that demonstrate ability to
lead a team and work independently.

Participants agreed that these five competencies are widely applicable to all retail settings and
levels of practice. The ability to provide high-quality customer service distinguishes retail clinics
from most other health care settings. Likewise, unlike in most other settings, clinic providers
are often solely responsible for managing the healthcare environment of the clinic without
depending on a broader system for administrative tasks and ensuring safety. It was
acknowledged that this requisite self-sufficiency marks a clear overlap in the core competencies
of healthcare environment and autonomy, and educators are encouraged to cultivate those
skills in tandem.

Address Gaps between Education and Practice Settings


Educators and retail health leaders agree that there may be gaps in knowledge and practice
requirements as graduates of advanced practice nursing and physician assistant programs
transition to retail health community-based settings. As the retail health model continues to
rapidly evolve, and because retail health-specific curriculum has not yet been developed in
most academic programs, measures must be put into place which allow for exposure to the
retail setting without slowing the growth and operations of the retail model.

Think Tank participants noted a need to develop well-devised programs that simultaneously
meet needs of young, unseasoned new hires and the needs of the current retail model. Faculty
and industry leaders identified various opportunities and strategies to build out more
sustainable, widespread clinical opportunities to meet these coinciding needs, including
establishing retail health practices run by faculty that could serve as clinical training sites.

Although clinics partially struggle with employee retention because some individuals are simply
ill-suited for the unique competencies required by the retail health industry, other losses are
traceable to a lack of mentorship and adequate training. Mentoring providers is an effective
way to strengthen the workforce while improving quality of care and patient outcomes.6
Participants shared the onboarding strategies of their organizations, ranging from two-week
intensive training programs for new employees, to six-month transition periods into
independent practice. The group explored the possibility of implementing more fellowships and
post-graduate mentoring programs for recent graduates who wish to make the transition to the
retail health industry, but are not immediately ready-for-hire.

Relying upon observations of new graduate providers in the field, seasoned retail health
providers and executives noted that many students are lacking thorough preparation on
business acumen. To decrease the common discomfort of students with topics such as finances
and profit-making in the provision of healthcare, retail health experts encouraged educators to
foster organic conversations with students about the fundamentals of running and growing a
business.

6
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from
http://books.nap.edu/openbook.php?record_id=12956&page=R1

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Build a Knowledge Base for Educators
Faculty in advanced practice nursing and physician assistant programs have expressed an
interest in understanding the composition of retail clinics, the scope of healthcare services
provided, availability of clinical sites and preceptors, nuances of clinic management, and
desired level of education and experience for new hires. Educators are also interested in
knowing how to incorporate the needs of the retail health industry and convenient care model
into their respective curriculums.

The following provides a summary of recommendations specific to this area:

→ Employ retail health providers as adjunct faculty to increase synergy


between retail health and educators. Encourage supervision of students in retail clinic
faculty practice arrangements.
→ Increase networking opportunities for academic programs and stakeholders in
retail health to foster partnerships and increase faculty knowledge of retail health.

→ Disseminate information about the expanding services of retail clinics


and their increasing capability to manage a variety of health issues, including
successful chronic disease management. Faculty agreed that broader awareness of
such capability would inherently make the retail health setting more appealing to
educators.
→ Encourage academic programs to host presentations and educational events
led by retail health clinicians with a student and faculty audience. Faculty expressed
interest in attending a national webinar on retail health best practices.

Collaborate on Policy Initiatives


Advanced practice nurses, physician assistants, and other non-physician providers often seek
congruent or mutually beneficial policy outcomes. Strategizing and implementing policy
initiatives collaboratively leverages stakeholder strengths, maximizes resources, and reduces
duplication of efforts. Think Tank participants discussed various policy initiatives that coincide
for all retail health providers and stakeholders.

Participants identified the following associated policy initiatives:

o Continue to decrease scope of practice limitations: In 28 states, nurse practitioners


are required to work in collaboration with or under supervision of a physician. This
limits the ability of nurse practitioners to practice to the full extent of their education
and training, and imposes a number of financial and logistical burdens on individual
clinicians and group practices. Similarly, the scope of practice of physician assistants
and other retail health providers is determined by applicable state laws, which control
the range of services they may provide and with what extent of supervision. Reducing
unnecessary limitations on practice that cause financial, logistical and administrative
strain should be a policy priority for retail health stakeholders.

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o Enforce existing scope of practice authorizations: In some cases, a provider’s scope of
practice may be limited by policies of retail health companies, networks, or individual
clinics to a further extent than is mandated by applicable state laws (e.g., requiring
nurse practitioners to collaborate with a physician in order to write prescriptions in a
state that does not statutorily mandate collaboration). Stakeholders should ensure
that retail health company policies are as permissive as applicable laws.
o Reduce regulatory barriers creating logistical/administrative strain: As with scope of
practice limitations, outdated or unnecessary state laws and regulations that cause
strain on retail health companies, clinics and/or providers should be dissolved or
amended. Participants agreed that a primary regulatory burden on retail health
companies are “corporate practice of medicine” (CPM) restrictions, which generally
prohibit corporations from practicing medicine or employing a physician to provide
medical services. Due to CPM laws, many companies must establish separate legal
entities in order for their clinics to contract with physicians in states that require
physician collaboration with non-physician providers. These separate legal entities are
expensive to establish and maintain, and do not add value to the clinics.
o Establish dual Medicaid and Medicare credentialing: State Medicaid enrollment has
increased by 16.7 million since 2013. Retail clinics are well positioned to serve as
access points for these enrollees; however, the process each state has established to
enroll new Medicaid providers can be lengthy, sometimes taking up to eight months to
complete. Stakeholders should work with legislators to draft language that would test
the effectiveness of a dual Medicare/Medicaid provider credentialing process. Under a
dual process, states would voluntarily agree to waive the credentialing requirements
for their state Medicaid programs for providers that have already met the
credentialing requirements for Medicare – eliminating the need to submit duplicate
documentation, reducing administrative burdens, shorting credentialing times, and
lowering costs. The dual credentialing process would also be open to all types of
primary care providers, creating the potential for wider partnerships.

o Bolster mental and behavioral health services and support: A number of participants
noted that despite increased attention on the need for improved mental health,
behavioral health, and substance abuse treatment options, regulations often limit the
ability of providers to adequately support and treat patients. For example,
buprenorphine prescriptions for medication-assisted treatment are highly regulated,
limiting the discretion of providers to prescribe buprenorphine to patients addicted to
opioids.
o Consider development of a multi-state provider licensing “compact”: In 25 Nurse
Licensure Compact (NLC) states, registered nurses can practice in any NLC state by
obtaining one compact, or multi-state, nursing license. Participants discussed the
value of an equivalent option for advanced practice retail health providers. A multi-
state license would allow providers the freedom to engage in telehealth practice
across state lines, as well as provide flexibility for providers to move to and work in
different states.

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o Address telehealth practice restrictions and regulatory inconsistencies: Telehealth
continues to be a major priority for state legislatures around the county.
Approximately 200 telehealth bills have been introduced since January 2017.
Participants stressed the importance of monitoring new telehealth legislation and
regulations to ensure that additional restrictions are not placed on retail clinic
providers using telehealth. One concern is that in some cases, new telehealth
legislation mandates additional physician supervision requirements on nurse
practitioners that surpass supervision requirements in state nurse practice acts and
regulations. Participants discussed the need to ensure the language of new telehealth
legislation matches the state scope of practice language governing nurse practitioners,
physician assistants and other non-physician providers.

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Recommendations
____________________________________________________________
The following key recommendations emerged from the Think Tank discussion, and further
develop propositions from the preceding Think Tank.

Develop clinical opportunities.


Retail clinic operators agreed that they are generally averse to hiring new graduates
lacking prior experience in a self-sufficient working environment. Advanced practice
nursing and physician assistant program administration and faculty should commit
to developing more opportunities for students to practice in the retail health setting
in order to make them more attractive hiring candidates. This includes formalizing
the preceptorship process and urging program administrators to assume the
responsibility of establishing relationships with preceptors, rather than expecting
students to independently identify preceptors and mentors from personal networks.

Develop post-graduate programs.


Although novice providers require training and adequate time to adjust to any
healthcare setting, the unique demands of the retail setting exacerbate the
challenges of inexperience, and present the need for opportunities to gain
familiarity in the security of a supervised, clinical environment. Clinics must be
deliberate about establishing training steps to adequately onboard new graduate
hires. Further, retail clinics would benefit from developing short-term post-graduate
fellowship programs. These programs ideally would commit to employing graduates
at salaries commensurate to experience and fostering mentorship during the
fellowship period, with the possibility of full-time hire pending fellow aptitude and
clinic budget.

Advance policy collaboratively.


Retail health providers and other industry stakeholders often share corresponding
policy-related goals. Policy initiatives, including those detailed above, may be
significantly more effective if pursued collaboratively by stakeholders that can
mutually benefit from their success. In particular, provider membership
organizations are encouraged to work together to identify policy goals, strategize,
and align efforts to obtain solutions more efficiently and vigorously.

Foster provider connection.


Retail clinics have generally operated on a single-provider model, increasing a sense
of isolation and making them a less attractive practice setting to potential hires.
Clinics with a larger budget may be able to hire additional providers. As this option is

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not typically feasible, clinics are encouraged to consider other methods of fostering
connections, such as facilitating relationships with providers at other clinic locations,
emphasizing the value of interdisciplinary team members, and maximizing use of
technology to make virtual connections.

Encourage standardization.
There is a logistical need to streamline the creation of partnerships between
educators and clinics. Formal agreements should be standardized to expedite
contracting, such as developing regionally applicable – not clinic-specific –
memoranda of understanding (MOUs). Academic institutions are also encouraged to
standardize clinical placement requirements (e.g., acceptable settings, preceptor
requirements, hourly/semester quota requirements). For scheduling ease, the retail
clinic student onboarding process should be aligned with the education timeline; for
instance, initiating the placement process earlier, permitting students to work in the
clinics as soon as the semester begins.

Improve messaging about the retail health industry.


Communication about the retail health industry could improve in both its reach and
content in the following specific ways:

 Scope of practice: A common misconception about the retail health industry is


that it is inherently limiting to a provider’s scope of practice, when in fact, a
provider’s full scope of practice is retained in the retail setting. Although some
services currently may not be offered by clinics – due to both variations in legal
scope of practice as well as practical confines of individual retail clinics –
providers’ skills and capacities will continue to be tapped into as clinics gradually
provide more expansive services. Instead of focusing on limitations,
communication disseminated about the industry should emphasize the unique
opportunities for autonomy and business management provided by retail health.

 New graduate appeal: Retail health employers are encouraged to reconsider the
mindset that new graduates are generally less desirable hires, as the benefit of
hiring graduates without backgrounds in other healthcare settings may be less
influenced by non-transferrable prior practices and, wielding a contemporary
outlook, better equipped to handle the “clients of today.”

 Industry-specific needs: Specific requirements, demands and core competencies


of a retail health provider should be clearly messaged, in order to ensure that
applicants understand the environment as well as to cultivate a better-suited
pool of applicants.

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 Higher education partners: Retail health representatives should emphasize the
willingness of the retail health industry to foster partnerships with higher
education. The industry should offer educational materials and resources about
the retail health setting to educators, including the variety of services provided
by retail clinics.

 Leadership opportunities: The retail health sector presents advanced practice


providers with the unique opportunity to transition beyond the clinic into
corporate operation and leadership roles within retail health organizations.
Providers with leadership proficiency are often considered for C-level positions
in the retail health industry – an infrequent option for clinicians in traditional
healthcare sectors.

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Conclusion
____________________________________________________________

CCA member clinic organizations have devised a successful business model for retail clinics that
has been brought to scale. A major opportunity of the retail health industry is the growth of
advanced practice providers to practice in the clinics. Similarly, the key to the future for
advanced practice nurses, physician assistants, and other providers is to engage in innovative
models of healthcare delivery, including retail health clinics. CCA is committed to forging the
connection by ensuring the readiness of recent graduates to thrive as retail health clinicians.
____________________________________________________________

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Acknowledgements
____________________________________________________________

CCA sincerely thanks all participants in the Retail Health Workforce


Strategy Think Tank discussion for their valuable involvement, and
particularly appreciates the contributions of the following panelists:

Ann Davis,
American Academy of Physician Assistants
David Hebert,
American Association of Nurse Practitioners
Shannon Idzik,
National Organization of Nurse Practitioner Faculties
Brian Valdez,
Convenient Care Association
Cheryl Fattibene,
National Nurse-Led Care Consortium
___________________________________________________________

CCA is grateful for the efforts of its Provider Workforce Committee


members in convening the Think Tank:

Paul Bennie, RediClinic Sandy Ryan, Walmart


Nate Bronstein, CCA Peter Goldbach, Health Dialogue
Meggen Brown, The Little Clinic Tine Hansen-Turton, CCA
Cathleen McKnight, The Little Clinic Frank Manole, CVS MinuteClinic
Kristene Diggins, CVS MinuteClinic Angela Patterson, CVS MinuteClinic
Cheryl Fattibene, CCA Andrea Preisinger, RediClinic
Susan Ferbet, Walgreens Peter Nordeen, FastCare

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