Accountable Care Organizations

Accountable Care Organizations Give an introduction using the below article. The Clinical Nurse Leader: Prepared for an Era of Healthcare Reform Brenda Recchia Jeffers, PhD, RN, and Kim S. Astroth, PhD, RN Brenda Recchia Jeffers, PhD, RN, is Chancellor and Dean, St. John’s College, Springfield, IL; and Kim S. Astroth, PhD, RN, is Assistant Professor, Mennonite College of Nursing, Illinois State University, Normal, IL. Keywords Clinical nurse leader, healthcare reform, integrated care delivery, nursing education Correspondence Brenda Recchia Jeffers, PhD, RN, Department of Nursing, St. John’s College, Springfield, IL E-mail: Brenda.jeffers@ stjohnscollegespringfield.edu Jeffers Astroth PROBLEM. Passage of the 2010 Patient Protection and Affordable Care Act will require change in the healthcare systems. The clinical nurse leader must be prepared to lead and shape the changing environment to achieve maximum outcomes for patients and families. Movement toward integrated care delivery across the care continuum, the transition of the Centers for Medicare & Medicaid Services to a value-based funding model, and accountability for high-quality, cost-effective care are just some of the drivers of this new integrated healthcare system. IMPLICATIONS. Reimbursement models that reward those health systems that are able to meet benchmark performance standards will result in major shifts in how health systems operate. Expertise in care coordination across the healthcare continuum is essential for maximum reimbursement. Payment for value instead of volume delivered is a major reimbursement transition coming to the acute care setting, necessitating increased attention to mining data necessary to capture quality patient outcomes for maximum reimbursement. CONCLUSIONS. The clinical nurse leader is ideally suited to function within these integrated systems of the future, and possesses the skills needed to assist healthcare systems to meet this challenge. The healthcare system, as we know it, is changing rapidly. With these changes, the nurse must be prepared to shape and lead the emerging environment to achieve the highest outcomes for patients and families. Some of the drivers of this emerging system are as follows: (a) movement toward integrated care delivery across the care continuum, (b) the Centers for Medicare & Medicaid Services’ (CMS) transition to a new value-based funding model, and (c) accountability for high-quality, cost-effective care. Reimbursement models that reward health systems meeting benchmark performance standards will result in major shifts on how health systems operate. The clinical nurse leader (CNL), a new nursing role introduced by the American Association of Colleges of Nursing (AACN) in 2003, is ideally suited to assist healthcare environments to meet this challenge. The CNL is a master’sprepared nurse generalist educated with competencies needed in this new time to assure quality healthcare delivery. The CNL focuses on safety, quality outcomes, evidence-based practice, care coordination, advocacy, and financial stewardship (AACN, 2007). This focus makes this care provider uniquely prepared to lead change and high performance across the health system. The Institute of Medicine (IOM) report, The Future of Nursing (2010), challenges the nursing profession, as well as the entire healthcare system, to examine the implications of their recommendation that all nurses work to the maximum extent of their education and leadership competencies. Examination of the master’s-prepared nurse generalist educated within the CNL curricular framework provides an opportunity to reflect on the graduate competencies, optimal function, and leadership opportunities for this nursing role. While the CNL role was designed prior to The bs_bs_banner AN INDEPENDENT VOICE FOR NURSING 223 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 Future of Nursing report and the passage of the 2010 Patient Protection and Affordable Care Act, IOM reports, such as the Health Professions Education: A Bridge to Quality (2003), influenced the development of the CNL role (AACN, 2007). The recent IOM round table on the learning health system (IOM, 2011) articulates that the use of high-quality evidence is imperative to achieve value-based care delivery within an improved healthcare system. The healthcare reform transitions taking place now and anticipated in the near future resonate with the educational competencies and role preparation of the CNL. The purpose of this article is to review major reforms coming to healthcare systems and to examine the fit of the CNL role to lead change during a time of system reform and transition. Healthcare Reform and Transitions Creating an integrated healthcare system that performs as a seamless system and serves the patient is the goal of major reform initiatives taking place today. Expertise in care coordination across the healthcare continuum is essential for maximum reimbursement for Medicare and Medicaid patients. Integration of health services and patient-centered medical homes are two organizational models poised to provide patients the right health care at the right time in the right setting with the best outcome. Payment for value instead of volume delivered is a major reimbursement transition coming to the acute care setting, necessitating increased attention to mining the data necessary to capture quality patient outcomes for maximum reimbursement. A brief review of these transitions follows. Integrating the Healthcare System A major shift in healthcare delivery is the focus on integrated healthcare services. The concept and definition of integrated care have been evolving (Cortese & Korsmo, 2009; Kodner, 2009), and are now the key strategies to achieve the quality and value imperatives of the Patient Protection and Affordable Care Act. Provisions within the Act identify specific strategies to achieve patient-centered, integrated health care that, and if achieved, will provide financial incentives to the healthcare provider. For example, new provisions in the Act will expand the care coordination in Medicaid and introduce for the first time care coordination for Medicare patients (Thorpe & Ogden, 2010). Consequently, aging clients with multiple but potentially preventable chronic illnesses will require more strategic coordination of care both in and out of the hospital. Health systems are aligning with physicians, and independent physician practices are aligning practices to have the optimal opportunity for care coordination and for providing patients the right care at the right place (Fisher, 2008). Interprofessional healthcare teams must work together to assure that when the individual interacts with the system, healthcare needs are quickly identified, care is coordinated, and a welldefined, follow-up process is in place (Thorpe & Ogden, 2010). Patient-Centered Medical Homes and Accountable Care Organizations (ACO) The healthy home or patient-centered medical home model provides a coordinated care environment that assists patients to move through this new integrated system (Associated Press, 2011; Fisher, 2008). The medical home aligns with a primary care practice, is patient-centered and team-driven, and serves to coordinate patients’ care to receive the most appropriate care within the most appropriate setting (Cassidy, 2010). The use of electronic health records and the ability to monitor the clinical outcomes of patients are a key to making such a coordinated effort a success. The Patient Protection and Affordable Care Act (2010) outlines that the goal of the patient-centered medical home is to use health teams to better coordinate and manage chronic disease, as well as decrease hospital readmissions. The concept of accountability is an important driver in healthcare reform reorganization. While the ACO has received much attention, there continues to be a lack of clarity around the benefits and drawbacks of becoming a designated ACO (Johnson, 2011). An ACO is responsible not only for care coordination, but also for the quality and costs for a particular patient population (Rittenhouse, Shortell, & Fisher, 2009). Not all organizations will meet the qualifications for or desire to become an ACO as volume and attainment of care benchmarks must both be demonstrated to qualify for this designation (Johnson, 2011). Additionally, the final decision regarding if an organization qualifies to become an ACO is made by the CMS, not the organization itself. In all cases, accountability within a high-quality, high-value environment remains a key component for the health system of the twenty-first century. Clinical Nurse Leader Prepared Healthcare Reform B. R. Jeffers and K. S. Astroth 224 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 Reimbursing for Value A major challenge facing healthcare systems will be to shift from reimbursement for volume to reimbursement for high performance and quality outcomes. Beginning in fiscal year 2013, a percentage of Medicare reimbursement will be withheld unless hospitals meet benchmark performance measures in outcomes and patient satisfaction. The percentage withheld is expected to increase in the coming years, but at this time the increase is unknown. Hospitals can earn monies back when performance is at or above benchmark (Lloyd, 2011). Measures of care processes, including clinical measures for surgical and cardiac care, and patients’ satisfaction with their care experiences have been designated as the primary value indicators in fiscal year 2013. Additional value measures, including efficiency and outcomes, will be tracked in subsequent years. Measures of patient experiences include but are not limited to nurse communication, pain management, communication about medications, and discharge information. Healthcare analysts are emphasizing that for hospitals to achieve these quality outcomes, a focus on assuring reliable measures, use of evidence-based practice, and skill in care coordination is needed (Health Care Advisory Board, 2010; Huron Consulting Group, 2011; Lloyd, 2011). Implications for the CNL Role The healthcare system changes, and reimbursement models require increased emphasis on care integration, care continuity, and delivery of the most effective evidence-based care for the best value. The integrated care system requires care providers to possess a patient-centered focus, and skills in care coordination and experience in interprofessional team care delivery. Likewise, the medical home practice may be seen as a driver for care integration, with one goal being the decrease in readmissions through interprofessional care coordination. ACOs and acute care facilities need care providers who have an understanding of reimbursement for clinical outcomes, evidence-based care, and skills in patient-centered care coordination. How then can nursing best lead the system to meet these challenges? The following sections will describe the preparation of the CNL, and outline why the CNL is a key nursing role possessing the education and leadership competencies to lead successful transition in this era of healthcare reform. CNL preparation, roles, and current documented impact will be highlighted. Current CNL Preparation While undergraduate education for the registered nurse introduces the generalist to changing healthcare system challenges, and provides a solid foundation in many areas, such as evidence-based practice, informatics, and leadership, the competencies acquired by the newly baccalaureate-educated nurse are not sufficient to lead the transformations occurring within the current system. The nurse prepared at the undergraduate level is educated to provide direct patient care to individuals and groups, and to demonstrate an initial understanding of evidence-based practice and informatics. However, given the undergraduate program focus and length, it is not possible to provide advanced competencies and skills at the level needed for leading the changing system demands, for example, advanced health assessment, organization systems, quality improvement, risk management, and information management to track patient outcomes. Graduate preparation and an advanced nursing degree are needed to prepare the nurse to fully gain these competencies. Recently, the AACN released an updated version of the Essentials of Master’s Education in Nursing. This document outlines the essential components of a program granting a master’s degree in nursing. These essentials provide standards for the master’s level preparation of the nurse to gain the necessary knowledge and skills to function as an expert practitioner in the new healthcare era. The recommended preparation of the CNL is mirrored in these nine essentials: science and humanities background, systems and organizational leadership, quality improvement and safety, translation and integration of scholarship into practice, informatics and healthcare technology, health policy and advocacy, interprofessional collaboration, clinical prevention, and master’s-level nursing practice (AACN, 2011). The core curricular elements of the CNL preparation include content encompassing the nursing leadership, clinical outcomes management, and care environment management (AACN, 2007). More specifically, the CNL preparation includes management of client outcomes within a framework of evidence-based quality improvement and client safety. Preparation begins with a solid foundation in the liberal arts, which allows for the development of B. R. Jeffers and K. S. Astroth Clinical Nurse Leader Prepared Healthcare Reform 225 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 problem-solving skills, an ability to interpret and manage data, the use of knowledge to develop critical thinking skills, and the application of social, economic, political, and ethical concepts to patient care problems (AACN, 2007). Other areas included in the education of the CNL are advanced physical assessment, pathophysiology, and pharmacology, in addition to advanced principles of communication, leadership, quality improvement, risk management, evidencebased care, information management, and change theory. The preparation also includes a minimum of 300 clinical hours of immersion learning and practicing in the CNL role. Ultimately, these educational components facilitate the CNL student in providing the care to best meet the needs of a microsystem of clients. After or near successful completion of an accredited CNL education program, the CNL student is eligible to take the voluntary national CNL certification exam. This exam contains content on areas such as nursing leadership, clinical outcomes management, and care environment management (Commission on Nurse Certification [CNC], 2008). Successful completion of this exam confers the right to use “CNL” as part of the nurse’s credentials (CNC, 2008). Although some expect some overlap between the role of the CNL and other advanced roles, the CNL is prepared as a generalist with enhanced knowledge in pathophysiology, pharmacology, and physical assessment. The advanced practice nurse, such as the nurse practitioner, and the clinical nurse specialist (CNS) typically focus on specific patient populations and function in an advanced provider role with prescriptive authority. While the CNS has education in healthcare systems, the CNL generalist education focuses, to a greater extent, on the skills needed to succeed in the era of system reform. The CNL provides and coordinates care at the point of care, and focuses on microsystem change and leadership, while the CNS has a more specialized population focus and works across the health system (AACN, 2004). The doctorate of nursing practice (DNP) is expected to be the foundational preparation for the advanced practice nurse. While the CNL typically will provide care coordination for a group of patients at the microsystem level, the DNP may provide or oversee care from a macrosystem perspective. For example, the CNL considers patient metrics on a group of patients in a hospital unit and will develop quality initiatives to address those metrics that need improvement. The DNP can be instrumental in helping implement the successful quality initiatives throughout the hospital. A DNP may focus on nursing systems administration, while the CNL is not intended for nursing management positions. Instead, the CNL is a patient care-focused leader and has a pivotal role in coordinating patient care from an interprofessional team. Status of the CNL Within Our Current System Since 2005, there have been over 1,300 graduates from CNL programs across the country (AACN, 2010). Lammon, Stanton, and Blakney (2010) indicated that CNLs can be employed successfully in a variety of settings, including acute care, rural health care, veteran’s health care, public health, and home care. There are some initial data describing the value of the CNL role with improved client outcomes. For example, CNL practice in several veteran’s administration (VA) health facilities has resulted in overall promising improvement in outcomes such as reductions in patient falls, hospital-acquired pressure ulcers, ventilator-associated pneumonia, and cancelled scheduled surgical procedures (Ott and Walter, 2009). In one VA system, Hix, McKeon, and Walters (2009) reported significant improvements in quality indicators after CNL implementation, including reductions in inpatient readmission rates, length of stay, patient falls, hospital-acquired pressure ulcers, and surgical infection rates. Stanley et al. (2008), examining the impact of CNL over a 3-month time period, reported improvements in multiple clinical outcomes in three hospitals: improvements in patient satisfaction, positive impact on new nurse retention, decreased length of stay, and improved care coordination. An increase in quality for CMS core measures was present across all case studies. Stachowiak (n.d.) reported outcomes from a 2-month CNL pilot in a progressive medicalsurgical acute care unit. Results indicated an increase in Press Ganey nurse measures and a decreased length of stay in the 2-month time period. The decrease in length of stay was reported to provide a savings of over $100,000. Additionally, the author presented a patient case study of chronic illness management, which illustrated a savings of just under $300,000 when a CNL was coordinating care. Much of the literature offers case studies and qualitative data to report the impact and return on investment of the CNL, and the initial data are promising. CNL practice partners are commended for their vision on the use of the CNL to improve client outcomes in a cost-efficient manner. The quality improvement, risk anticipation, and financial consciousness in Clinical Nurse Leader Prepared Healthcare Reform B. R. Jeffers and K. S. Astroth 226 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 Table 1. Features of the Healthcare System Environments Matched With Clinical Nurse Leader (CNL) Competencies Features of the changing healthcare system Key features of the environment CNL competenciesa Integrated health care • Reimbursement for care coordination in chronic illness • Alignment of physicians and acute care • Patient receives the right care in the right setting • Interdisciplinary • Electronic communication essential for coordination Identifies clinical and cost outcomes that improve safety, effectiveness, timeliness, efficiency, quality, and the degree to which they are client-centered. Uses information systems/materials/ techniques to facilitate clients’ learning and improve their health outcomes. Communicates effectively to achieve quality client outcomes and lateral integration of care for a cohort of clients. Assimilates and applies research-based information to design, implement. and evaluate client plans of care. Uses information systems and technology at the point of care to improve healthcare outcomes. Patient-centered medical home • Patient-centered • Primary care focus • Interdisciplinary team moves patient through health system according to needs Effects change through advocacy for the interdisciplinary healthcare team and the client. Assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting, recognizing the influence of the meso- and macrosystems on the microsystem. Properly delegates and utilizes the resources (human and fiscal), and serves as a leader and partner in the interdisciplinary healthcare team. Accountable care environment • Accountable care organizations • Focus on defined population • Care coordination • High volumes • Tracking outcomes • Costs and quality Assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting. Uses information at the point of care to improve client outcomes. Synthesizes data, information, and knowledge to evaluate and achieve optimal client and care environment outcomes. Reimbursement for value • Outcomes determine reimbursement • Data-driven • Patient experience metrics • Tracking clinical processes and outcomes Implements cost-effective, quality outcomes that are safe, timely, efficient, and client-centered. Participates in systems review to critically evaluate and anticipate risks to client safety to improve quality of client care delivery. Synthesizes data, information, and knowledge (e.g., patient satisfaction and other quality indicators) to evaluate and achieve optimal client and care environment outcomes. Facilitates client care using evidence-based resources. Note: aAdapted and/or reprinted from White Paper on the Education and Role of the Clinical Nurse Leader by the American Association of Colleges of Nursing, 2007, pp. 34–38. Copyright 2007 by the American Association of Colleges of Nursing. B. R. Jeffers and K. S. Astroth Clinical Nurse Leader Prepared Healthcare Reform 227 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 CNL preparation fit nicely with the challenges of value-based purchasing. In addition to the length of stay cost-savings reported with CNL pilots, the reports of the CNL impact in improving core measures and Press Ganey nurse measures show promise for acute care facilities to capture additional Medicare reimbursement in value-based purchasing. The lateral integration of care (care coordination), resource management, and advocacy inherent in the CNL role will be important in accountability for discharge planning that can minimize early readmission. The CNL attention to microsystem data will promote growth on the use of information technology at a microsystem level as a means for tracking patient outcomes, the ultimate measure of the CNL role. Table 1 illustrates some of the key features of the new healthcare systems and select competencies of the CNL role that are best suited to meet the needs of these new systems. More research is needed to demonstrate the value of this new nursing role and its impact on outcomes vital to the demands prompted by healthcare reform. Summary The CNL is well suited to take a leading role within the identified domains of change for and the new healthcare system. The CNL has a preparation and focus in several areas that are critical to the successful transition to the new era of health care. Specifically, the CNL focus on care coordination across the healthcare continuum is vital in ensuring efficiency in managing care for the client. Furthermore, the emphasis on data management and on the use of metrics to track client outcomes is critical to ensure cost-effective, quality client care with appropriate outcomes. References American Association of Colleges of Nursing. (2003). 2003 Annual report. Retrieved from http://www.aacn.nche. edu/publications/annual-reports/AR2003.pdf American Association of Colleges of Nursing. (2004). Working statement comparing the clinical nurse leader and clinical nurse specialist roles: Similarities, differences and complementarities. Retrieved from http://aacn.nche.edu/ cnl/CNLCNSComparisonTable.pdf American Association of Colleges of Nursing. (2007). White paper on the education and role of the clinical nurse leader. 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Stachowiak, M. (n.d.). Clinical nurse leader: Quantative(sic) and qualitative outcomes. Unpublished manuscript. Stanley, J. M., Gannon, J., Gabuat, J., Hartranft, S., Adams, N., Mayes, C., . . . Burch, D. (2008). The clinical nurse leader: A catalyst for improving quality and patient safety. Journal of Nursing Management, 16, 614–622. doi:10.1111/j.1365-2834.2008.00899.x Thorpe, K. E., & Ogden, L. L. (2010). Analysis and commentary: The foundation that health reform lays for improved payment, care coordination, and prevention. Health Affairs, 29, 1183–1187. doi:10.1377/hlthaff.2010.04 B. R. Jeffers and K. S. Astroth Clinical Nurse Leader Prepared Healthcare Reform 229 © 2013 Wiley Periodicals, Inc. Nursing Forum Volume 48, No. 3, July-September 2013 Copyright of Nursing Forum is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. 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