Agenda Comparison Grid and Fact Sheet or Talking Points Brief

American Academy of Nursing on Policy

Policy agenda for nurse-led care coordination Gerri Lamb, PhD, RN, FAAN, Co-Chaira,

Robin Newhouse, PhD, RN, NEA-BC, FAAN, Co-Chairb, Claudia Beverly, PhD, RN, FAANc, Debra A. Toney, PhD, RN, FAANd, Stacey Cropley, DNP, RNe, Charlotte A. Weaver, PhD, RN, FAANf,

Ellen Kurtzman, MPH, RN, FAANg, Donna Zazworsky, MS, CCM, RN, FAANh, Marilyn Rantz, PhD, RN, FAANi, Brenda Zierler, PhD, RN, FAANj,

Mary Naylor, PhD, RN, FAAN, Expert Reviewerk, Sue Reinhard, PhD, RN, FAAN, Expert Reviewerl, Cheryl Sullivan, MSES, Staffm,*,

Kim Czubaruk, Esq, Staffm, Marla Weston, PhD, RN, FAAN, Staffn, Maureen Dailey, PhD, RN, CWOCN, Staffn, Cheryl Peterson, MSN, RN, Staffn, and

Task Force Members aArizona State University bUniversity of Maryland

c John A. Hartford Center of Geriatric Nursing Excellence dNevada Health Centers Inc. eTexas Nurses Organization fGentiva Health Services Inc.

gGeorge Washington University hCarondelet Health Network

iUniversity of Missouri-Columbia jUniversity of Washington kUniversity of Pennsylvania

lAmerican Association of Retired Persons mAmerican Academy of Nursing nAmerican Nursing Association

I. Introduction and Statement of Policy Priorities

The Care Coordination Task Force (CCTF) was convened in mid-2014 by the leadership of the Amer- ican Nurses Association (ANA) and the American Academy of Nursing (AAN) to review major position papers and policy briefs on care coordination pub- lished between 2012 and 2013 by expert panels of both organizations, and to recommend specific and action- able federal policy priorities to advance nursing’s contributions to effective care coordination. Nurses have been and continue to be pivotal in the develop- ment and delivery of innovative care coordination practice models. The 2011 Institute of Medicine Report on the Future of Nursing (Institute of Medicine, 2011) emphasized the nursing profession’s long-term strength in improving the quality, access and value of

* Corresponding author: Cheryl Sullivan, American Academy of Nursi E-mail address: [email protected] (C. Sullivan).

0029-6554/$ - see front matter http://dx.doi.org/10.1016/j.outlook.2015.06.003

health care through care coordination. The rapid changes transforming health care today and increased demand for care coordination require immediate action to enable nurses and other qualified health professionals to deliver outstanding care coordination to achieve the nation’s quality agenda as outlined in its National Quality Strategy (NQS; Agency for Healthcare Research and Quality [AHRQ], 2011). Recognizing this urgent need, ANA and AAN charged the CCTF with translating seminal documents crafted by their mem- bers into a blueprint for policy action.

Members of the CCTF prioritized policy recommen- dations to support and reduce barriers for nurses to practice the full scope of their care coordination expertise.

They acknowledged that members of other profes- sional and nonprofessional groups also are instru- mental in the implementation of care coordination interventions. Their approach was to generate general

ng, 1000 Vermont Avenue, NW, Suite 910, WA.

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overarching policy priorities that may be aligned with interprofessional colleagues with supporting short- term (within one year) and longer-term (within three years) strategies thatmaximize nursing’s contributions.

The task force supports implementation of the following policy recommendations and short-term strategies to contribute to effective care coordination in traditional and community settings. Long-term strategies to support and advance the short-term strategies also are discussed.

Policy priorities

Policy priority #1: Payment should be expanded for consistency across all qualified health professionals delivering high-value care coordination activities, including bachelor’s-prepared nurses.

Short-term strategy #1: Create provisions for pay- ment of care coordination based on a set of common tasks delineating qualifying providers for payment and providing payment with supporting docu- mentation.

Short-term strategy #2: Advocate for inclusion of team-based accountability and transparency.

Short-term strategy #3: Advocate for full scope of practice of advanced practice registered nurses (APRNs).

Short-term strategy #4: Identify bachelor’s-prepared registered nurses (RNs) as qualified providers of care coordination services.

Policy priority #2: Accelerate the design, endorsement and use of rigorously tested care coordination mea- sures, including those central to the domains of nurse care coordination.

Short-term strategy #1: Solicit promising care coor- dination measures from the nursing community.

Short-term strategy #2: Convene a national group to identify effective strategies to increase funding streams for the development and testing of care co- ordinationmeasures central to the domains of nurse care coordination practice.

Short-term strategy #3: Refine and strengthen stra- tegies to seat expert nurses on national care coor- dination measure development and review panels.

II. Background and Guiding Principles

The CCTF was convened by ANA and AAN to prioritize policy options for advancing care coordination and to propose actionable strategies and leadership to advance their implementation. As an initial step in drafting policy recommendations, task force members reviewed seminal policy and position papers on care coordination prepared by AAN and ANA expert panels and work groups:

� The imperative for patient-, family- and population- centered interprofessional approaches to care coor- dination and transitional care: A policy brief by the American Academy of Nursing’s CCTF, Nursing Outlook 60 (2012), 330-333. (Cipriano, 2012).

� The importance of health information technology in care coordination and transition care,Nursing Outlook 61 (2013), 475-479. (Cipriano et al., 2013).

� The value of nurse care coordination: A white paper of the ANA, Nursing Outlook 61 (2013), 490-501. (Camicia et al., 2013).

� Framework for measuring nurses’ contributions to care coordination, ANA Care Coordination Quality Measures Professional Issues Panel, October 2013.

Following review of these papers, CCTF members gathered information about recent developments in care coordination practice, measurement and pay- ment. With the assistance of project staff, they gener- ated a comprehensive list of potential priority areas for advancing care coordination, including payment for all qualified health professionals, payment for team- based care, performance measurement, health infor- mation technology, development and expansion of best practice models, workforce development, com- mon definitions and service scope, outcome research, incentives for patient and family engagement, and standardization of competencies for accreditation and maintenance of certification.

Task force members then ranked these areas ac- cording to importance for advancing care coordination practice and its outcomes, alignment with current and pending policies relevant to care coordination, and feasibility of short-term success in policy change and funding. They reached a consensus on two key priority areas on which to initially focus their policy recom- mendations: (1) expanding payment at an equitable and consistent rate for care coordination provided by all qualified health professionals; and (2) developing, implementing and evaluating performance measures to accelerate high-value care coordination provided by the United States health care system.

Members of the task force believe that these two priority areas are consistent with recommendations from ANA and AAN position papers and are core to advancing the quality of care coordination practice and outcomes by nurses and other qualified health pro- fessionals. While the policy recommendations for care coordination payment and performance measurement are presented separately, task force members viewed them as highly interdependent and supported by evi- dence, much of which emanates from high-value care coordination models provided by nurses that have been developed, implemented, and evaluated for de- cades (see Figure 1).

As a first step, the CCTF members established guiding principles in which to situate their policy recommendations. They emphasized the importance of removing barriers to effective care coordination by supporting APRNs and RNs in their ability to practice

Figure 1 e Task force framework for care coordination policy recommendations.

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to the full extent of their education and training. The ability to accurately attribute the unique contributions of nurses working independently or as members of a team was viewed as central to professional practice and all policy recommendations. Without linkages to attribution, nursing’s contributions are silent, and the ability to examine activities and interventions of the nurse is limited. The value of nursing interventions on patient health must be examined and known to promote transparent accountability and advance both payment and performance measurement.

Drawing from the work of the ANA panel, the CCTF identified additional principles that ground their policy recommendations: accessible (i.e., that payment opti- mizes access to care), equitable, rational, evidence- based, patient-/family-centered, interprofessional, inclusive, accountable, and efficient (or resourceful). Somemembers cited theneed for comprehensible rules and transparency in public reporting of data regarding care coordination outcomes to enhance consumer selection of higher-value health care.

III. Policy Priority #1: Payment Should Be Expanded for Consistency across All Qualified Health Professionals Delivering High-Value Care Coordination Activities, Including Bachelor’s-Prepared Nurses

Reimbursement to all qualified health professionals who deliver care coordination services is needed to promote high-quality/value care coordination and facilitate patient choice to better achieve patient-/ family-centered outcomes. Payment has the best op- portunity to stimulate value when constrained only by performance expectations. Payment should be directed to the highest-performing care coordination practice d regardless of which health care professional pro- vides these services. Evidence suggests nurse-led care

coordination or team-based models in which nurses play a central role are effective. Nurses will then need to emphasize the knowledge and skills they bring to care coordination, as will all eligible health professionals.

Expanding payment to all qualified professionals will actualize an interprofessional health care work- force inwhich the health professionalmost qualified to deliver the highest-performing care coordination practice to meet the needs of patients/families delivers care coordination services for peoplewith complex and chronic conditions. These services are often needed in challenging settings, working with vulnerable pop- ulations in which nurses often lead care coordination teams. While our recommendation starts with pay- ment for all qualified health professionals, develop- ment of a long-term payment strategy for team-based accountability is in order. We should support value- based purchasing that promotes flexibility in how payment is made and enables nurses to receive pay- ment for high-quality, efficient care coordination.

The first policy strategy focused on payment is viewed as urgent and foundational to advance nurs- ing’s contributions to effective care coordination. As noted previously, nurses serve a central role in diverse models of care coordination for people with complex illnesses across health care settings, demonstrating impressive health care quality and lower costs (Camicia et al., 2013). Yet most of the current and proposed payment models focus on physicians and APRNs and do not recognize the significant contribu- tions of bachelor’s-prepared RNs or the efforts of other health professionals who contribute to care coordina- tion as members of interprofessional teams.

Currently, there are a few initiatives and pieces of legislation that may offer an opportunity to introduce payment for all qualified health professionals. The Department of Health and Human Services recently announced that it will be creating a Health Care Pay- ment Learning and Action Network (Centers for Medicare and Medicaid Services [CMS], n.d.) to spread value-based payment models, which may provide a venue to test innovative care coordination models nationally. Additionally, CMS proposed changes to the payment policy under the Physician Fee Schedule for chronic caremanagement (CCM; Department of Health and Human Services, 2014). Coordination of care ser- vices that are non-face-to-face will be reimbursed for Medicare beneficiaries with two or more chronic con- ditions expected to last at least 12 months. APRNs will be eligible for reimbursement, but, as yet, non-APRN nurses working to the full scope of their education, training and licenses, and other health professionals beyond physicians, will not.

Policy Priority #1: Short-Term Strategies

Four short-term strategies are priorities for achieving policy priority #1. These strategies are aimed at speci- fying performance expectations for care coordination

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and recognizing and measuring contributions of all qualified health professionals who contribute to care coordination individually and as members of an interprofessional team.

Short-Term Strategy #1: Create Provisions for Payment of Care Coordination Based on a Set of Common Tasks Delineating Qualifying Providers for Payment and Providing Payment with Supporting Documentation Specification of high-value care coordination activities is central to payment policy. While this work is un- derway and represented in ANA and AAN documents reviewed by the task force, it is not complete and de- mands immediate attention.

ANA and AAN should appoint a task force to identify professional organizations that represent providers that may be eligible for reimbursement for care coor- dination; develop a taxonomy of structures, processes, and outcomes for care coordination; and work with CMS to advocate for a common taxonomy and to harmonize definitions for use inmeasure development and evaluation. The taxonomy should be matched to RN and APRN tasks as qualified providers.

Short-Term Strategy #2: Advocate for Inclusion of Team- Based Accountability and Transparency Emerging delivery models including accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) rely on effective teamwork and collaboration to ensure professional practice at full scope and achievement of NQS priorities, including care coordination. Current payment models do not recognize the high-value care coordination activities provided by health professionals other than those identified as qualified providers. Along with clear specification of high-value care coordination activities, paving the way for equitable payment for care coordi- nation requires advocating and developing the infra- structure for:

� Team-based accountability for high-value care coor- dination: Providers must recognize that care coordi- nation activities require contributions of team members best-prepared to carry out these activities.

� Transparency: National Provider Identifier data should be collected for all teammembers and include bachelor’s-prepared RNs and APRNs to ensure attri- bution and commensurate payment. Transparency related to care coordination activities is needed to determine the optimal mix of clinicians with the right staffing/skill mix to yield the best outcomes for specific populations at risk.

ANA should take the lead on developing and implementing advocacy tactics for team-based accountability and transparency and should partner with ANA organizational constituencies and affiliates, including AAN expert panels, specialty nursing orga- nizations, and other stakeholders.

Short-Term Strategy #3: Advocate for Full Scope of Practice of APRNs Current care coordination payment models include provisions for APRN payment. Short-term strategy #3 is aimed at better positioning APRNs to lead and influ- ence the development, implementation and evaluation of high-value care coordination models. To date, a few APRNs have successfully formed PCMHs. Their impact on care coordination activities and relevant outcomes in these settings should be closely monitored.

In addition, strategies should be undertaken to include APRNs at the highest levels of other emerging practice models, such as ACOs. There is a shortage of primary care providers limiting access to care for vulnerable populations to the right care, at the right time, with the right clinician team (e.g., timely palliative/end-of-life care, chronic care, etc.). Lack of timely access reduces patient-/family-centered care and increases cost due to avoidable adverse events (e.g., avoidable emergency department admissions and readmissions).

ANA and AAN should advocate to have the final rule amended to authorize APRNs as eligible providers to certify plans of care across all care settings, prioritizing post-acute care/long-term care settings (specifically home health care, nursing homes, assisted living and skilled nursing facilities) as a beginning to improve patient-centered care outcomes (e.g., reduce rehospi- talization). ANA and AAN should identify organiza- tions that are already working on authorizing APRNs to certify plans of care across all care settings, prioritizing post-acute care/long-term care settings.

Short-Term Strategy #4: Identify Bachelor’s-Prepared RNs as Qualified Providers of Care Coordination Services Bachelor’s-prepared nurses have led and contributed to care coordination models for decades. Care coordina- tion is an essential competency for all bachelor’s-pre- pared nurses (American Association of Colleges of Nursing, 2008; ANA, 2010). Bachelor’s-prepared nurses have the education and experience to (1) direct care coordination across settings and among caregivers, including oversight of licensed and unlicensed personnel in any assigned or delegated task; and (2) partner with other clinicians and caregivers in inter- disciplinary teams to promote positive patient out- comes (ANA, 2010). Yet their care coordination activities are not recognized or included in any current or proposed payment model. For the most part, high- value care coordination activities delivered by bache- lor’s-prepared nurses are attributed and paid to pro- fessionals currently designated as qualified providers.

ANA should advocate for bachelor’s-prepared nurses to practice to the full extent of their education and experience, and for their designation as qualified providers; their payment should not be rolled into payment for other providers (similar to being included in bed-and-board in hospitals). ANA’s regulatory team

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should work with constituencies to ensure that final rules include team-based accountability, transparency and appropriate health professionals (including bach- elor’s-prepared nurses) in the reimbursement for CCM.

Longer-Term Considerations

Task force members identified several longer-term initiatives to support and advance achievement and maintenance of the short-term payment priorities.

� Monitor and evaluate the transition from fee-for- service to capitation and optimize the benefits of capitation to support care coordination.

Evaluation will be of primary importance as com- mons sets of tasks are identified (short-term strategy #1), team-based accountability is enhanced (short- term strategy #2), and APRNs’ and bachelor’s-prepared nurses’ full scope of practice is realized (short-term strategies #3 and #4). As capitated payment for care coordination is implemented, ANA and AAN should evaluate the impact of changing reimbursement on economic and patient outcomes. They should advocate for permember permonthmodels, which are capitated models of reimbursement, as they will reduce clinician burden for billing (e.g., CPT codes for CCM) and reduce the opportunity for gaming.

� Support and advocate for testing of innovative nurse- led and interprofessional high-value care coordina- tion models.

There is mixed evidence supporting various models of care coordination. The Community-based Care Transitions Program funded by CMS evaluation is still underway. A generation of new, innovative models of care coordination that are both nurse-led and inter- professional is needed. For example, research indicates that family members recognize the need and take re- sponsibility for many care coordination activities. Consumer-drivenmodels of care to pay for needed care coordination services and to reimburse family mem- bers and significant others for high-value care coordi- nation activities will likely involve APRNs and bachelor’s-prepared nurses in care coordination ser- vices. Funders will need to commit to a program of research to test the efficacy and effectiveness of these new models of care.

ANA and AAN shouldworkwith CMS to advocate for testing care coordination interventions in all relevant Center for Medicare and Medicaid Innovation (CMMI) initiatives, including the Bundled Payments for Care Improvement initiative. They also should work with AHRQ and the Patient-Centered Outcomes Research Institute (PCORI) to encourage funding for multisite cluster trials of nurse-led care coordination in- terventions, including those with consumer-driven options.

IV. Policy Priority #2: Accelerate the Design, Endorsement, and Use of Rigorously Tested Care Coordination Measures, Including Those Central to the Domains of Nurse Care Coordination

The importance of robust measures of care coordina- tion practice was highlighted in each of the founda- tional papers reviewed bymembers of the CCTF. AAN’s policy briefs on patient-, family- and population- centered interprofessional approaches to care coordi- nation and transitional care and health information technology recommended immediate policy action to “expedite funding to develop, implement and evaluate performance measures that address gaps in effective and efficient care coordination” (Cipriano, 2012) and harmonize data elements and standards requirements for a single patient-centered, consensus-based, longi- tudinal plan of care that is interoperable and accessible to patients, families, and all providers across all set- tings (Cipriano et al., 2013). ANA’s white paper on the value of nurse care coordination and its framework for measuring nurses’ contributions to care coordination specified principles to guide measurement develop- ment, including transparency, parsimony, evidence- based, comprehensiveness, and interprofessional teamwork, as well as measurement domains associ- ated with effective nurse care coordination practice.

In the short period since these papers were pub- lished and widely disseminated, there have been a few promising advances in care coordination performance measurement. In 2013, as part of its reorganization, NQF established a standing committee on care coor- dination performance measures with a nurse as co- chair. NQF also convened a new work group to address measurement gaps in care coordination. This work group proposed a new definition of “care coordi- nation” to guide measure development and revisions to the 2006 NQF measurement domains, thereby bringing them into close alignment with the goals and strategies of the national quality agenda (Table 1). The ANA framework for performancemeasurement of care coordination was one of the source documents used to inform these changes.

In addition to these definition and framework re- finements, CMS, AHRQ and the National Committee for Quality Assurance (NCQA) have embarked on funded initiatives to develop new care coordination measures. CMS has been a significant leader in closing the mea- sures gap through its Measure Management System Blueprint. AHRQ has funded the American Institutes for Research to develop a new Care Coordination Quality Measure for Primary Care as part of its Care Coordination Measures Development Phase III pro- gram. NCQA is currently convening work groups to develop new care coordination measures for Medicare Advantage Plans. PCORI has an interest in health sys- tem interventions and has funded a major national

Table 1 e Changes in NQF’s Care Coordination Definition and Measurement Domains, 2006 and 2014

Topic 2006 2014

Definition of “care coordination”

A function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions and sites are met over time.

The deliberate synchronization of activities and information to improve health outcomes by ensuring that care recipients’ and families’ needs and preferences for health care and community services are met over time.

Measurement domains

� Health care home. � Proactive plan of care and follow-up. � Communication. � Information systems. � Transitions or handoffs.

� Joint creation of a patient-centered plan of care. � Use of a health neighborhood to execute plan of care.

� Achievement of outcomes.

Sources: National Quality Forum, 2006; National Quality Forum, 2014b.

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study to investigate which transitional care services are most effective in improving patient-centered out- comes. Results will provide evidence supporting structure and process measures for care coordination.

Although the launch of each of these initiatives suggests greater interest in developing a robust set of care coordination measures that reflect changes in health care and evolving care coordination practice models, there is still a paucity of endorsed care coor- dination performance measures. Only one new care coordination measure was submitted to NQF for endorsement in the previous two review cycles. Most of the currently endorsed measures are setting- or “eligible provider”-specific and are limited to a very small set of the refined NQF measurement domains. Measure development activities convened by AHRQ, and NCQA are in the very early stages. Most existing measures are low-level (e.g., check box) process mea- sures. The right mix of high-impact structure, process and outcome measures is needed. Patient-reported outcomes also are needed.

While there is considerable discussion of the shortcomings of the current care coordination mea- surement set, there also is recognition that develop- ment and testing of new measures are expensive and time-consuming, with few sources of funding. In addition, the feasibility of capturing data for more robust measures is a challenge. Significant gaps remain in domains of care coordination integral to nurse care coordination practice, including shared decision-making in the patient-/family-centered plan of care, shared accountability among team members for the plan of care, timeliness and accountability of services, care recipient and family experience of care coordination, and impact on quality outcomes and costs of care.

Setting the Stage for Performance Measurement Policy Strategies

Task force members identified several issues affecting the current context andpolitical environment for policy recommendations and strategies related to advancing care coordination performance measurement.

Definition of “care coordination”: Definitions of “care coordination” driving performance measurement continue to evolve. Different definitions are being used to guide measure review, endorsement and regulation. The CCTF reviewed the variety of definitions available and evaluated their alignment with domains proposed in the ANA’s Framework for Measuring Nurses’ Contributions to Care Coordination (ANA Care Coordination Quality Measures Professional Issues Panel, 2013). Recognizing that the ANA framework informed NQF’s most recent changes to its care coor- dination definition and domains, the task force mem- bers proposed that their policy recommendations build on the 2014NQF consensus definition and highlight key aspects central to nursing in the development of the care coordination measurement set. Task force mem- bers affirmed the importance of patient-/family- centeredness, patient engagement, integration of care, the full continuum of care and payment in NQF’s defi- nition and measurement domains, and recommended that each of these elements be made more explicit in future revisions. Policy strategies for advancing care coordination performance measurement must be guided by a strong patient-centric model that empha- sizes patient and family engagement and collaboration with providers across the care continuum of care planning and evaluation. There needs to be an emphasis on the human interaction that is founda- tional to effective care coordination intervention as well as the workflow and sequencing components included in the definition.

Priority measures: The current set of care coordi- nation performance measures has significant gaps in areas that are central to nurse care coordination practice and to core competency areas required for payment to all qualified health professionals. Imme- diate priorities for filling these gaps identified by task force members include:

� As feasible, a harmonized set of care coordination measures across the full continuum of care, including primary care, acute care, post-acute and long-term care, hospice, assisted living, and com- munity services.

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� Screening and risk assessment measures that cap- ture evidence-based risk assessment at each point of care.

� Implementation of endorsed medication reconcilia- tion measures.

� Advanced care planning. � Patient engagement competencies for care coordi- nation and transitional care.

eMeasures: As recommended in the AAN paper on health information technology, the development of care coordination measures needs to anticipate re- quirements for eMeasures that support standards and interoperability and accessibility to patient-/family- centered care coordination data.

Team-based care coordination measures: Care co- ordination is commonly defined and operationalized in the context of interprofessional teamwork, shared accountability and collaboration. The processes of care coordination require expert integration and synchro- nization between and among patients, families, pro- fessional and lay providers, and health care and community settings, as reflected in current definitions and frameworks. Translating shared accountability and determining attribution of care coordination to the individuals and groups that have the requisite com- petencies and actually do the work are significant is- sues and tension points in the care coordination payment dialogue. The members of the CCTF support team-based measures for care coordination in philos- ophy; they believe that considerably more analysis and discussion are required before team-based measures are proposed as a policy priority.

Policy Priority #2: Short-Term Strategies

Three short-term strategies are priorities for achieving policy priority #2. These strategies are aimed at creating a wider pool of potential care coordination measures from nurses in practice, generating funding for measure development and testing, and positioning nurses on key committees guiding selection of care coordination performance measures.

Short-Term Strategy #1: Solicit Promising Care Coordination Measures from the Nursing Community There is no question that nurses are leading and participating in the development and refinement of care coordination models in all practice settings. Ex- amples of the range of nurse-led models for patient- centered medical homes, post-acute and long-term care, and transitional care are evident in published literature as well as the numerous conferences on care coordination, continuity of care, care across the continuum, and other related topics. Many of the preferred practices that are used to guide develop- ment and support NQF’s care coordination perfor- mance measures derive from programs and models developed by nurses in which nurses lead and pro- vide the majority of the care coordination

interventions in multiple roles. It is likely that many nurse care coordination programs are using home- grown and/or standardized performance measures to capture structures, processes and outcomes of care coordination. Few, if any, of these measures are being developed to meet rigorous endorsement criteria. Since only one new care coordination measure was submitted for NQF review in the previous two review cycles, it is questionable whether nurses are aware of the need and opportunity to develop nascent mea- sures or the process needed to submit them for endorsement.

Nurse-developed and -led care coordination pro- grams may be a rich and untapped source of measures to fill the care coordination measurement gap, particu- larly in the domains of care coordinationmost reflective of nursing interventions and contributions to care co- ordination. As a first step in moving toward perfor- mance metrics, the state of development of care coordinationmeasures should be established.Measures should capture the actual practice work of care coordi- nation and can be used to define competencies and payment for all qualified health professionals. The task force recommends that ANA and AAN develop a work- ing group with the Nursing Alliance for Quality Care (NAQC) and membership from all nursing specialty groups to conduct a national campaign to solicit care coordination measures being used in nurse care coor- dination programs. ANA, AAN and nursing specialty organizations should survey research-intensive mem- bers (including AAN Edge Runners) to determine if care coordination measures have been developed and used within nurse-scientist-conducted research studies.

Short-Term Strategy #2: Convene a National Group to Identify Effective Strategies to Increase Funding Streams for the Development and Testing of Care Coordination Measures Central to the Domains of Nurse Care Coordination Practice Growth of the care coordination measurement set is severely limited by the lack of funding for measure development and testing. The few measure develop- ment initiatives currently funded are targeted to spe- cific practice settings (e.g., primary care), eligible providers and/or specific populations (Medicare Advantage members). Expanding funding streams for measure development and testing is essential to improve the state of performance measurement for care coordination.

The CCTF recommends that ANA and AAN convene a national task force with the major funders of care coordination measure development and testing, including CMS, AHRQ and major organizations influ- encing the selection and endorsement of care coordi- nation measures used for payment guidelines, such as NCQA, the Measurement Application Partnership (National Quality Forum, 2014a) and NQF, to review measurement gaps in care coordination and propose initiatives to fund development and testing of care coordination measures that align with core nursing

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domains and achievement of the national quality agenda goals.

Short-Term Strategy #3: Refine and Strengthen Strategies to Seat Expert Nurses on National Care Coordination Measure Development and Review Panels Key decisions about development, evaluation and se- lection of measures for national payment programs like value-based purchasing are initiated and influ- enced within expert panels, task forces and standing committees. The nursing community has made tremendous strides in the past several years in seating nurse experts on care coordination on committees at CMS, AHRQ and NQF.

The CCTF recommends that ANA and AAN convene a task force to review and strengthen current processes to identify andplacenurse experts on care coordination performance measurement committees in order to in- crease the number of nurses on these committees and to prepare for succession planning.

Longer-Term Consideration

� Evaluate the value and feasibility of team-based care coordination measures.

As already discussed, CCTFmembers acknowledged potential advantages of team-based measures for capturing the actual delivery of care coordination ser- vices and addressing accountability and attribution issues. The current state of team performance mea- surement is not well-developed, and there is no consensus about how these measures may be feasibly operationalized or implemented within payment pol- icy. The CCTF recommends further analysis of the value and feasibility of these measures.

r e f e r e n c e s

Agency for Healthcare Research and Quality (AHRQ). (2011). National strategy for quality improvement in health care. Retrieved from http://www.ahrq.gov/workingforquality/.

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education- resources/BaccEssentials08.pdf.

American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: ANA.

ANA Care Coordination Quality Measures Professional Issues Panel. (2013). Framework for measuring nurses’ contributions to care coordination. Retrieved from http://nursingworld.org/ Framework-for-Measuring-Nurses-Contributions-to-Care- Coordination.

Camicia, M., Chamberlain, B., Finnie, R. R., Nalle, M., Lindeke, L. L., Lorenz, L., . McMenamin, P. (2013). The value of nursing care coordination: A white paper of the American Nurses Association. Nursing Outlook, 61(6), 490e501.

Centers for Medicare and Medicaid Services (CMS). (n.d.). Health care payment learning and action. Retrieved from http:// innovation.cms.gov/initiatives/Health-Care-Payment- Learning-and-Action-Network/

Cipriano, P. (2012). The imperative for patient-, family- and population-centered interprofessional approaches to care coordination and transitional care: A policy brief by the American Academy of Nursing’s Care Coordination Task Force. Nursing Outlook, 60(5), 330e333.

Cipriano, P. F., Bowles, K., Dailey, M., Dykes, P., Lamb, G., & Naylor, M. (2013). The importance of health information technology in care coordination and transitional care. Nursing Outlook, 61(6), 475e489.

Department of Health and Human Services. (2014). Federal register proposed rules (No. CMS-1612-P). Baltimore, MD: Centers for Medicare and Medicaid Services.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

National Quality Forum. (2014a). Measure applications partnership. Retrieved from http://www.qualityforum.org/setting_ priorities/partnership/measure_applications_partnership. aspx.

National Quality Forum. (2014b). Priority setting for healthcare performance measurement: Addressing performance measure gaps in care coordination. Retrieved from. http://www. qualityforum.org/Publications/2014/08/Priority_Setting_for_ Healthcare_Perf.ormance_Measurement__Addressing_ Performance_Measure_Gaps_in_Care_Coordination. aspx.

National Quality Forum. (2006). NQF-endorsed definition and framework for measuring care coordination. Retrieved from www. qualityforum.org.

Summary of Care Coordination Policy Priorities, Short-Term Strategies and Longer-Term Considerations

Care Coordination Policy Strategies Lead Organizations

Payment Short-term strategies Payment should be expanded for

consistency across all qualified health professionals delivering high-value care coordination activities, including bachelor’s- prepared nurses.

1. Create provisions for payment of care coordination based on a set of common tasks delineating quali- fying providers for payment and providing payment with support- ing documentation.

2. Advocate for inclusion of team- based accountability and transparency.

ANA and AAN should appoint a task force in the private sector to develop the taxonomy of common tasks, match tasks to qualified providers (RNs and APRNs), and advise CMS and other payers on evidence from research. Representatives from CMS, AHRQ, PCORI and other payers may be invited to participate in the task force.

ANA should take the lead on developing and implementing advocacy tactics for team-based accountability and transparency, and partner with ANA organizational constituencies (organizational affiliates and other specialty nursing organizations, such as geriatric nursing groups and AAN expert panels) and other stakeholders (e.g., payers, consumers) as buy-in is solidified.

3. Advocate for full scope of practice of APRNs.

Specifically, ANA and AAN should

advocate to have the final rule

amended to authorize APRNs as

eligible providers to certify plans of

care across all care settings, priori-

tizing post-acute care/long-term care

settings (specifically home health

care, nursing homes, and assisted

living and skilled nursing facilities)

as a beginning to improve patient-

centered care outcomes (e.g., reduce

rehospitalization).

ANA and AAN should identify organizations that are already working on this (there is proposed legislation with bipartisan support). Begin with Robert Wood Johnson Foundation, AARP (Campaign for Action) and Johnson & Johnson.

4. Identify bachelor’s-prepared RNs as qualified providers of care co- ordination services.

ANA and AAN should employ multiple strategies, resources, levers and constituencies. Consumers Union may be a potential partner.

Longer-term considerations 1. Monitor and evaluate the transi-

tion from fee-for-service to capitation, and optimize the benefits of capitation to support care coordination.

ANA and AAN should evaluate the impact of changing reimbursement on economic and patient outcomes.

2. Support and advocate for testing of innovative nurse-led and interprofessional high-value care coordination models.

ANA and AAN should work with CMS to advocate for testing care coordination interventions in all relevant CMMI initiatives, including the Bundled Payments for Care Improvement initiative. They also should work with AHRQ and PCORI to encourage funding for multisite cluster trials of nurse- led care coordination interventions.

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Care Coordination Policy Strategies Lead Organizations

Performance measurement Short-term strategies Accelerate the design, endorsement

and use of rigorously tested care coordination measures, including those central to the domains of nurse care coordination.

1. Solicit promising care coordina- tion measures from the nursing community.

ANA, AAN, NAQC and nursing specialty organizations should determine the state of development of care coordination measures. A survey of research- intensive members, including AAN Edge Runners, should be conducted to determine if care coordination measures have been developed and used within nurse- scientist-conducted research studies.

2. Convene a national group to identify effective strategies to in- crease funding streams for the development and testing of care coordination measures central to the domains of nursing care co- ordination practice.

ANA and Academy to work with CMS, AHRQ, NQF, NCQA, Office of the Assistant Secretary for Health, key stakeholder groups, e.g., consumers and other purchasers. Start with CMS.

3. Refine and strengthen strategies to seat expert nurses on national care coordination measure devel- opment and review panels.

ANA, Academy, and NAQC to convene a working group to review current procedures and processes and propose strategies for timely appointments.

Longer-term consideration 1. Evaluate the value and feasibility

of team-based care coordination measures.

The AAN expert panel should work with CMS and the Physician Consortium for Performance Improvement.

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