Difficulty in closing the evidence to practice gap has

Transcription

1 Nurses Improving the Care of Healthsystem Elders: Creating a Sustainable Business Model to Improve Care of Hospitalized Older Adults Elizabeth A. Capezuti, PhD, Barbara Briccoli, MPA, and Marie P. Boltz, PhD The Nurses Improving the Care of Healthsystem Elders (NICHE) program helps its more than 450 member sites to build the leadership capabilities to enact system-level change that targets the unique needs of older adults and embeds evidence-based geriatrics knowledge into practice. NICHE received expansion funding to establish a sustainable business model for operations while positioning the program to continue as a leader in innovative senior care programs. The expansion program focused on developing an internal business infrastructure, expanding NICHEspecific resources, creating a Web platform, increasing the number of participating NICHE hospitals, enhancing and expanding the NICHE benchmarking service, supporting research that generates evidence-based practices, fostering interorganizational collaboration, developing sufficient diversified revenue sources, and increasing the penetration and level of activity of current NICHE sites. These activities (improved services, Web-based tools, better benchmarking) added value and made it feasible to charge hospitals an annual fee for access and participation. NICHE does not stipulate how institutions should modify geriatric care; rather, NICHE principles and tools are meant to be adapted to each site s unique institutional culture. This article describes the historical context, the rationale, and the business plan that has resulted in successful organizational outcomes, including financial sustainability of the business operations of NICHE. J Am Geriatr Soc 61: , Key words: hospital care; sustainability; organizational models; hospital administration; clinical innovations From the College of Nursing, New York University, New York, New York. Address correspondence to Elizabeth A. Capezuti, NYU College of Nursing, 726 Broadway, Room 1042, New York, NY ec65@nyu.edu DOI: /jgs Difficulty in closing the evidence to practice gap has been recognized for decades. 1 Although governmental agencies and professional associations have developed clinical guidelines to streamline the process of research translation for efficient uptake, widespread adoption remains elusive. 2 The implementation of effective geriatric models of care is an equally daunting task. 3 5 Knowledge transfer and uptake is not simply changing individual clinician s behavior; it requires embedding system-level facilitators that address mission, human and material resources, and work climate. 6,7 Guidelines and care models also need to be flexible enough for individualization to the local context. Nurses Improving the Care of Healthsystem Elders (NICHE) is an organization of more than 450 active member sites representing individual hospitals and nearly 100 health systems in North America. To meet its vision that all older adults will be given sensitive and exemplary care, NICHE helps its member sites build the leadership capabilities to enact system-level change that targets the unique needs of older adults and embed evidence-based geriatric knowledge into practice The NICHE office at New York University College of Nursing is a technical support center for sites providing educational, clinical, and operational tools through a Web-based portal and conferences. Details concerning the program components, including the NICHE implementation process for hospitals and the benchmarking services, can be found elsewhere. 10,11,13 20 NICHE, similar to other geriatric programs, has been found to be valuable to the small number of hospitals that implement it. In 2006, a plan was developed to establish a sustainable income base for operations while positioning the program to continue as a leader in nurse-led innovative practices for senior care. This article describes the historical context, the rationale, and the business plan that have resulted in successful organizational outcomes, including financial sustainability of the business operations of NICHE. JAGS 61: , , Copyright the Authors Journal compilation 2013, The American Geriatrics Society /13/$15.00

2 1388 CAPEZUTI ET AL. AUGUST 2013 VOL. 61, NO. 8 JAGS NICHE Development: In 1981, Dr. Terry Fulmer initiated the Geriatric Resource Nurse (GRN) model at Boston s Beth Israel Hospital. 21 The GRN model is an educational and clinical intervention model that prepares staff nurses as the clinical resource people on geriatric matters to other nurses on their units. She then adapted the GRN model within a geriatrician-led care team at Yale New Haven Hospital as part of the John A. Hartford Foundation s Hospital Outcomes Program for the Elderly initiative ( ). 22 The John A. Hartford Foundation provided funds in 1992 to New York University to field-test the GRN and other nursing care models in the broader hospital community. 23 This project became known as NICHE, which aimed to create a better care environment for older hospitalized adults by improving nursing practice. An advisory board of geriatric nursing experts helped to develop a portfolio of clinical resources that was field tested in eight hospitals. 23 NICHE became an integral program of the Hartford Institute for Geriatric Nursing when the latter was initially funded in NICHE spread slowly but consistently through exposure at national conferences and nursing publications. In 2003, an experienced geriatric nurse practitioner and health system administrator became the practice director, whose effective outreach and mentoring stimulated a period of more-rapid growth. She provided extensive support to sites in the area of process implementation and clinical content. Her areas of responsibility included annual conference planning and outreach activities for NICHE that tripled new site enrollment. This growth increased demand for mentoring of new sites and usage of the Web site and tools. Although interest in NICHE grew rapidly, the internal infrastructure, staffing, and revenue stream in 2006 was beyond the capacity to support the interest of new sites and mentor the progress of existing programs. This also coincided with the reduction of funding from the John A. Hartford Foundation to the Hartford Institute for Geriatric Nursing. Business Model One hundred fifty-seven hospitals in 2006 participated in NICHE with minimal cost and commitment, but many voiced considerable interest in maintaining the peer interaction and development of a more-robust portfolio of resources. Dr. Christopher Langston, a program officer at the Atlantic Philanthropies foundation in 2006, encouraged several directors of geriatric models to explore how they could expand to sustainable businesses while meeting their core mission of facilitating high-quality geriatric care. The NICHE team, facilitated by a business consultant, evaluated its core competencies and aspirations for the NICHE programs future capabilities and effect on the care of older hospitalized adults. The resulting 5-year ( ) business plan was intended to significantly increase internal capacity to stimulate and support new adopters and support important improvements in tools, database, Web site, and programming to ensure that programs that NICHE sites implement with sufficient rigor will affect the hospital-wide care of older adults. The foundation s $5 million grant to NICHE provided the social venture capital to support capacity-building activities (Table 1). 25 The funder s investment was meant to support initial operational development while a membership fee model was initiated that would, after 5 years, financially sustain NICHE operations. CAPACITY-BUILDING ACTIVITIES Increase Organizational Capacity A critical aspect of the business plan was the development of a sustainable core of 6 10 internal staff who could efficiently oversee and direct contracted experts for clinical tool development, Web and information technology support, marketing, and professional conference management. Two faculty (approximately 0.4 FTE) and a 0.5 FTE staff member who were able to lead the development of clinical organizational resources, expand the benchmarking service, and promote research initiatives were already in place. The hiring of a managing director was needed to transform a program within an academic institution into an entity that mostly functioned like a small nonprofit membership organization. This new organizational structure consists of the Director (also the principal investigator of the grant), who leads the organization and the research and fund-raising activities; the Managing Director, who oversees all operations; and the Director of Education (formerly Practice Director), who focuses on resource and program development and serves as the content expert. The titles, role functions, and qualifications of the 11-person staff of NICHE are available from the corresponding author. NICHE partners with a Web development firm and a communications firm. The latter works closely with the internal team to develop and execute marketing activities. A learning management system provider has partnered with NICHE to develop the Web-based platform to host courses and resources and track all users. A Web-based survey company developed a new Web system for benchmarking and evaluation. Table 1. Target Activities and Outcomes of Nurses Improving the Care of Healthsystem Elders (NICHE) Business Plan ( ) Increase organizational (NICHE central New York University College of Nursing office) capacity Develop NICHE-specific resources that target gero-specific staff development, clinical practice guidelines, organizational strategies, and program evaluation Create the platforms (Web sites, learning management system, and other virtual platforms for knowledge management) for individual and site development Enhance and expand NICHE benchmarking service Support research, internally and collaboratively, that generates evidence-based practices Increase the number of hospitals participating in the NICHE program Harness the talent and commitment of successful NICHE sites through intentional engagement as mentors, resource content experts, and ad hoc committee members Increasing the penetration and level of activity of current NICHE sites Foster interorganizational collaboration that includes additional grant funding to expand resources and programs Generate diversified revenue sources to sustain NICHE program operations

3 JAGS AUGUST 2013 VOL. 61, NO. 8 NICHE: CREATING A SUSTAINABLE BUSINESS MODEL 1389 Develop NICHE-Specific Resources An extensive profile of clinical, organizational, and educational resources (Table 2) is meant to bridge the geriatric training gap, achieve real system-wide improvement, and empower patients and their families. Organizational resources (Table 3) guide NICHE sites to implement their individualized change initiative regarding care of older adults. Clinical resources, listed in Table 2, demonstrate the breadth of clinician training tools; NICHE launches on average one new resource each month. These resources are not static items but require continual updating; changes in practice evidence and standards compel the development of new tools to increase the depth of the NICHE portfolio. Most are member only because the costs connected with content development and the platform (e.g., Web-based learning management system, webinars) to deliver these effectively necessitate a significant level of member fees. Create a Web Platform for Individual and Site Development Table 2. Nurses Improving the Care of Healthsystem Elders (NICHE) Clinical Resources Geriatric Resource Nurse (GRN) Core Curriculum is designed for use by those at NICHE sites who train nurses in best practices for older hospitalized adults Introduction to Gerontology Curriculum provides a foundation for developing geriatric sensitive care across all hospital departments Geriatric Patient Care Associate (GPCA) Core Curriculum consists of active learning modules aimed at developing geriatric sensitive care within the role of the patient care associate Nursing Care of the Older Adult with Cancer provides the nurse clinician with practical information regarding the complexities and special considerations associated with caring for older adults with cancer, in all practice settings Critical Care Nursing of Older Adults provides evidence-based guidelines for the nurse clinician working with older adults in critical care, step-down-units, and trauma and emergency departments NICHE Webinars address clinical topics, management approaches, and regulatory imperatives General Discussion Forums help NICHE sites interact with others involved in the NICHE designation process, other NICHE sites, and NICHE experts Education Briefs are concise PowerPoint in-services that focus on clinical care issues and trends pertinent to the GRN and bedside caregivers ability to provide evidence-based care The NICHE Need to Know series provides concise information on a variety of topics such as delirium prevention and promotion of functional recovery for consumers Table 3. Nurses Improving the Care of Healthsystem Elders (NICHE) Organizational Resources Leadership Training Program is a 38-hour, self-paced, Web-based, blended-learning training program held over 6-week period to guide NICHE implementation The NICHE Planning and Implementation Guide provides the most current content for full implementation of NICHE in an acute care setting Clinical Improvement Models are series of modules providing an overview of system-level adoption of clinical best practices, including a Restraint Reduction Program, Pressure Ulcer Prevention Program, and Reducing the Risk of Fall-Related Injuries NICHE Organizational Strategies are a series of toolkits designed to assist sites in securing financial and organizational support for the NICHE program, such as a hospital-level certification campaign and Patient Family Advisory Councils The Cost Savings Estimate Model enables hospitals to measure the financial outcomes of NICHE within their hospitals and units Crosswalk: Joint Commission Standards and NICHE Resources details how NICHE resources comply with Joint Commission standards in terms of care of older adult hospital patients NICHE Benchmarking Service provides tools for measurement of staff knowledge, unit-level outcomes, program status, and improvement gains NICHE Hospitals Reports identify the positive outcomes linked to innovative initiatives experienced at NICHE designated hospitals in their care of older adults NICHE Solutions Series are success stories from NICHE hospitals based on the application of best practices Media Kit & Marketing Resources include a variety of high-profile marketing and outreach materials available to NICHE hospitals to help communicate their commitment to improving care for older adults and their families and promote their NICHE designation NICHE Conferences are annual congresses of interdisciplinary healthcare professionals to share current research, quality initiatives, and innovative practices related to the care of older adults Speaker s Bureau provides sites with access to geriatric specialist and other experts for speaking engagements The economic crisis affected how some of the resources are delivered and catapulted the program into its current extensive online learning platform. Because hospitals were reducing travel to conferences in 2008, the traditional method of becoming a NICHE site attending an annual Leadership Training Program (LTP) immediately before the annual conference was eliminated and changed to an online LTP that is a blended learning approach in which participants participant in a 20-hour program that spans 6 weeks delivered on a Web-based platform and facilitated by NICHE faculty and mentors. The ever-increasing access to Web-based resources, tools, and products provide members with a cost-effective alternative to purchasing these items individually from multiple sources. The Web site serves as a platform for program announcements and registration, audio conferences, and webinars and a Web-based marketplace featuring NICHE products for sale. The NICHE Web site gram.org is informational and promotional. Information is organized so that messages are carefully crafted to hospital administrators and clinicians, consumers of health care (including families), and NICHE members. The Web site seamlessly takes users to the NICHE Knowledge Center where all of the tools, resources, courses, and discussion boards are housed. The latter provides peer-to-peer communication that accelerates spread of best practices and tools, with NICHE as the facilitator. User enrollment has grown to 430 hospitals, 25 affiliated long-term care facilities, and more than 20,000 users since its introduction. Enhance and Expand NICHE Benchmarking Service Measurement and evaluation are critical to implementing and sustaining the NICHE model across all settings. The NICHE Benchmarking Service provides NICHE sites access to a portfolio of survey instruments that can assess progress

4 1390 CAPEZUTI ET AL. AUGUST 2013 VOL. 61, NO. 8 JAGS in organizational attributes such as perceived work environment, knowledge competencies, and unit-level patient outcomes. Since 2007, these surveys are provided through Web-based data entry and provide automated benchmarking reports of several valid and reliable instruments, including the NICHE Geriatric Institutional Assessment Profile (GIAP). 12 NICHE uses a survey platform that was customized to enhance the operation of the NICHE surveys for site coordinators and respondents and for the benchmarking service. It provides self-service options for NICHE sites, including setup and report generation, as well as real-time tracking of respondents. Benchmarking reports are designed for easy interpretation of results, whether for benchmarking against other NICHE hospitals (with similar bed size and teaching), comparing results by unit internally, or before and after NICHE implementation. There are 99,000 completed GIAP surveys (from February 1997 to present). A comprehensive description of the NICHE database and the GIAP is found elsewhere. 12,26 Support Research that Generates Evidence-Based Practices The NICHE research team, composed of geriatric nursing research faculty and staff, has conducted several psychometric studies of various scales within the GIAP The NICHE research team is also testing new items applicable to new settings, including long-term care settings. Secondary data analysis projects using the NICHE benchmarking database continue to provide a rich source for exploring how institutional, geographic, and unit-level factors influence the geriatric-specific work environment of nurses. 8,9,30,31 The NICHE research team helps NICHE sites participate as a network of study sites for research. Researchers at New York University or affiliated with NICHE sites recruit sites to participate in a variety of studies. One example is the Agency for Healthcare Research and Quality funded project, in 20 NICHE sites, that is determining whether electronic audit feedback regarding catheter duration and catheter-associated urinary tract infections will change urinary catheter management. 32 Many NICHE sites value the opportunity to participate in multisite studies that have a direct effect on their practice. Increase Participating NICHE Hospitals NICHE actively engages experienced NICHE clinicians, administrators, and educators to support fledgling sites, inform policy and resource development, and disseminate the work of NICHE. Seasoned NICHE leaders (mentors) serve as faculty in the leadership training program and act as mentors to new sites, constituting a large network of coaches who support regional growth. NICHE members also serve on committees that work on the annual conference content, the NICHE program evaluation, Web site upgrades, and resource development and evaluation. An extensive marketing and communication strategy aims to engage healthcare providers and institutions. These efforts have resulted in a steady increase in new members: those entering NICHE through the Leadership Training Program (LTP) and those that choose to continue in yearly fee-based membership. Figure 1 demonstrates the increase in NICHE-designated sites. Increase the Penetration and Level of Activity of Current NICHE Sites In September 2010, an annual self-evaluation was integrated into the recommitment process, when hospitals renew their NICHE designation. The process was developed in response to members requests to demonstrate progress and accountability to their internal stakeholders. The content of the self-evaluation was developed in NICHE research that engaged the views of clinicians, consumers, and gerontological researchers to identify the components of a geriatric acute care program. 33 Hospitals use data in their internal planning and evaluation. The depth and penetration of the NICHE program is evaluated in the dimensions of guiding principles, organizational structures, leadership, geriatric staff competence, interdisciplinary resources and processes, patient- and family-centered approaches, environment of care, and quality measures. Hospitals are recognized at four levels of implementation: early implementation, progressive implementation, senior friendly, and exemplar. 34 Most sites are at the progressive level, and one-quarter are considered to be at the senior-friendly or exemplar level. Another indicator of NICHE site engagement is sites presentations at the annual conference, where their overall attendance has more than doubled (178 in 2007 to 550 in 2012). Podium presentations are selected through a competitive peer-review process, and podium and poster presenters share their work in NICHE webinars, the Solutions series, and the NICHE column in the journal Geriatric Nursing. Foster Interorganizational Collaboration NICHE is also collaborating with organizations to build consumer advocacy and drive system-wide initiatives in the care of older adults. For example, NICHE is working closely with the Catholic Health Association to improve integration of care within their member institutions, including 600 hospitals across the United States. NICHE is also supporting the efforts of the Emergency Nurses Association as they develop an emergency department core curriculum, Develop Sufficient Diversified Revenue Sources Much of the activity (improved services, Web-based tools, better benchmarking) is intended to add value and make it Figure 1. Growth of Nurses Improving the Care of Healthsystem Elders (NICHE) designated sites.

5 JAGS AUGUST 2013 VOL. 61, NO. 8 NICHE: CREATING A SUSTAINABLE BUSINESS MODEL 1391 feasible to charge hospitals an annual fee for access and participation. The recognition by peer hospitals and consumers of NICHE designation is a critical component of the value proposition. Some services (e.g., webinars) continue to be available to nonfee participants but at higher rates. This was implemented in large scale when most of the capabilities were in place, and the conversion or recruitment of hospitals into a recognized cadre of formal participating status had been implemented. NICHE launched an annual membership fee structure in September In addition to retaining more than 75% of the original NICHE hospitals during the transition, more than 176 hospitals and 25 affiliated non-acute care facilities have joined NICHE since the transition. In September 2011, the first renewal period for fee payers, more than 97% were retained, whereas the second cohort in January 2012 realized a retention rate of 100%. New hospitals pay for training and designation through the LTP and then pay an annual fee. The training and membership fees are the primary source of income. A critical metric of the success of NICHE is the sustainable revenue streams that support program operations. NICHE has successfully launched an annual designation fee, along with a rigorous renewal process yielding more than $4.3 million over 5 years (Figure 2). Despite financial challenges, NICHE has succeeded in establishing a sustainable income base for operations. Why Successful? Several factors have contributed to success in building a financially sustainable program. The foundations funding to develop a business plan provided the opportunity to assess the program s strengths and weakness and to provide access to other competencies (business, marketing, information technology, and Web experts) that helped to visualize the potential of the program and the concrete steps required to achieve goals. Forecasting realistic costs and revenues provided a clear direction of where there is a need to outsource to vendors and consultants in areas that were not financially or practically feasible to keep in house. The subsequent funding of the expansion plan provided the means to develop the operational infrastructure to support bold programmatic objectives. The budget was conservative, to compensate for uncertain financial issues. Figure 2. Nurses Improving the Care of Healthsystem Elders (NICHE) revenue. LTP = leadership training program; fy = fiscal year; proj = project (year). Although the latter did not include the global economic crisis that began in 2008, the agility of the team to revise the business strategy as new products (e.g., move from conference-based to online learning model for the NICHE LTP) were tested and implemented, significantly helped to keep on track. In addition, the planned phase-in of feebased services allowed interest and price point to be tested incrementally and adjustments to be made as needed. It also gave the sites a year to plan for this change and to rally internally in their health systems for inclusion of NICHE fees within their annual budgets. Although the initiation of the fee structure had to be delayed from 2009 to 2010, it was not too late to minimize the risk of becoming over extended or reaching the end of the grant period and having a high hurdle of revenue generation to implement rapidly. Instead, that extra year was used to ramp up the development and design a complex array of related NICHEspecific resources and services within a user-friendly platform, which helped to gain the confidence and widespread engagement of NICHE sites to embrace a fee-based membership model. The grant funding was loaded in the beginning years so that building core capabilities could be invested in. The grant revenue then began tapering down in 2010 so that, by 2012, the program would be entirely dependent on members fees. Another strength is that operational leadership was sought from an individual with a broad-based business background (Masters in Public Administration) and extensive experience in directing small nonprofit programs, including membership organizations. The competencies of two faculty (one with healthcare administrative experience and the other an experienced researcher) and the Managing Director are complementary. The commitment is apparent to NICHE staff (and sites) and has kept the program attentive to specific goals. Although NICHE functions within an academic research environment, a missiondriven organizational framework is maintained. The mission led from an expert-directed, top down organization to a more membership participatory organizational structure through committee participation, online surveys, and discussion forums. This shared approach enhances the relevancy of the tools. Furthermore, the online learning community facilitates peer support to implement NICHE-based hospital initiatives. Spotlighting site achievements on the Web site and featuring site success and innovations as NICHE Solutions encourages sharing between NICHE sites who take part in an ongoing collaborative that contributes resources and experiences. A distinguishing feature of NICHE is that, unlike other programs, it does not stipulate how institutions should modify geriatric care; rather, it provides the materials and services necessary to stimulate and support the planning, implementation, and evaluation process. NICHE principles and tools are meant to be adapted to each site s unique institutional culture. It is not merely a collection of useful resources but is the online community that supports discussion of how to use the resources that value. NICHE is the most likely program to be able to charge fees for these services because of their pertinence and practical usefulness to hospital nursing leaders. Nurse administrators embrace NICHE as a modest investment to address the hospital-acquired conditions that occur more

6 1392 CAPEZUTI ET AL. AUGUST 2013 VOL. 61, NO. 8 JAGS frequently in older adults (e.g., pressure ulcers, functional decline, delirium) that can result in hospital readmissions. It would be much more costly and difficult to recruit geriatric nurse specialists to develop and deliver the expansive resources that NICHE provides. The focus of NICHE is on programs and protocols that are predominantly influenced by nursing practice; in other words, areas where nursing interventions have a substantive effect on patient care. This is important because all geriatric models depend on significant nursing input to coordinate and implement; thus the uptake of these models often requires the buy-in of nurse administrators. Similar to other geriatric models, NICHE is designed to increase nurse competence to care for older adults and to be effective members of the interdisciplinary team, but NICHE also emphasizes nurse involvement in hospital decisionmaking regarding care of older adults. 3,7 This is a consistent with the growing trend toward professional nursing practice models promulgated by the Magnet program, which recognizes healthcare organizations for nursing excellence. A significantly high proportion of NICHE sites are also Magnet, adding another incentive to hospital nursing leaders. The limitation of the NICHE business model is that other approaches to care of older adults that complement NICHE principles are not incorporated. Other geriatric care models have not received the same level of social venture capital to facilitate their development, which impedes effective programmatic collaboration. This is important because facilitating of health system level geriatric service lines or similar entities require geriatric models that educate all disciplines and incorporate nonclinicians (e.g., families and volunteers) across settings. NICHE has built internal capacity to manage and facilitate tremendous growth, but there are considerable internal challenges of operating a lean, efficient, small, nonprofit business model embedded in a large academic setting. The administrative processes have had to be managed and navigated at the university level, including adherence to university compensation scales and space limitations. Virtual staff and consultants have been hired, providing access to highly qualified staff and consultants, regardless of their location. FUTURE DIRECTIONS Several initiatives are underway to increase and diversify revenue streams. To meet a growing interest in NICHE, the program will have to undergo another expansion in the learning management system (LMS; to support future goals for e-learning, inventory of best practices utilization and other data, and enhanced peer-to-peer exchange). The pricing structure has been adjusted based on number of LMS users, but it is likely that additional capital will be needed, or with an LMS or another professional membership organization will be partnered with to scale up the Web-based resource portal. A new business plan will be developed to review the options to meet the growing demand for the high-quality program while effectively expanding NICHE operations in an efficient organizational structure. To accelerate NICHE adoption over the next 5 years, various ways to move NICHE effectively to the next operational level are being considered. NICHE has the infrastructure to expand beyond its current membership base so that it can partner with other programs that disseminate geriatric models of care. The Medicare Innovations Collaborative (also funded by The Atlantic Philanthropies foundation) pilot tested a geriatric portfolio or service line approach in which several geriatric models are implemented simultaneously but customized to each of the six healthcare organizations local circumstances. 35 NICHE was the most commonly adopted model and was viewed as foundational for building a hospital s culture of quality and safety. 35 This makes sense because NICHE principles complement other models and because all of these programs require significant nursing input to provide services or oversee the model and its interdisciplinary team. The next step is a new level of national-level collaboration in which the national groups representing these various geriatric care model programs work together to advance adoption, especially if coupled with clear guidelines for tracking patient and financial outcomes. 3 Consolidating resources and sharing costs between programs has the potential to expand the reach of all of these programs. ACKNOWLEDGMENTS The authors would like to thank the NICHE sites for their dedication to excellence in care of older hospitalized patients. Conflict of Interest: Each author works in the NICHE program described in the manuscript, and part of their salary has been paid by a grant funding the project from Atlantic Philanthropies, Inc. ( ). Author Contributions: All authors contributed to the preparation of the paper. Sponsor s Role: None. The business plan described in this paper was funded by Atlantic Philanthropies, Inc. REFERENCES 1. 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