Healthcare Delivery Models & Nursing Practice

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patient-centered medical homes will be integral to accountable care organizations.

According to Shortell (2010): The appeal of the ACO concept lies in its ability to accommodate or respond to any of the new pay- ment mechanisms – full capitation, partial capita- tion, bundled or episode-of-care-based payment – and various add-on payments for coordinating care or achieving defined quality and cost results (p. 17).

To enhance quality and cost effectiveness, an ACO needs to be able to:

1. Care for patients across the continuum of care, in dif- ferent institutional settings as well as the home

2. Plan, prospectively, for budgets and resource needs 3. Effectively use evidence-based protocols and compar-

ative effectiveness research 4. Develop and support comprehensive, valid, and reli-

able measurement of performance (Devers & Berenson, 2009)

Shortell (2010) goes on to describe other benefits of ACOs:

ACOs create incentives for hospitals and physicians to reduce unnecessary admissions through better disease prevention and primary care; reduce pre- ventable readmissions through better coordinated care; and reduce unnecessary and costly use of hos- pital emergency rooms. The hospital business model shifts from maximizing inpatient care mar- gins to maximizing total care margins (p. 17).

So how do nurses contribute to cost-effective patient care in the PCMH and ACO? A major focus in PPACA is cost-effective care of patients with chronic illness, especial- ly those with multiple co-morbidities. Certainly, advanced practice nurses (APNs) will be a part of the health team in these environments providing, based on their education and certification, primary or specialty care to patients with multiple chronic illnesses.

There are also major opportunities for ambulatory care registered nurses (RNs) to provide and expand their work with advocacy, education, and care coordination to these populations using evidence-based practice protocols. Prior fee-for-service payment mechanisms have incentivized patients’ visits to the physician. In the PCMH, where the patient is known to the entire health team, telephone/elec- tronic mechanisms may be used to monitor and access patients, triage patients to appropriate care sites and providers, and teach or counsel patients in their homes. The RN in ambulatory care will often be the initial telehealth contact for patients. Using evidence-based algorithms, the ambulatory care RN can triage, educate, and counsel the patient and often avoid an ambulatory visit or a visit to the emergency room or readmission to the hospital. Telehealth is commonly used in capitated care; it is a major cost saver for the health care organization and a patient satisfier.

Health Reform Act: New Models of Care and

Delivery Systems Previous columns have discussed how the Patient

Protection and Affordable Care Act (PPACA), now a law, focuses on health promotion and prevention and offers opportunities for ambulatory care nurses to enhance serv- ices to patients and families. This month’s column will focus on new delivery systems and models of care. PPACA offers incentives to develop, test, and evaluate these new delivery systems, and it is essential that ambulatory care nurses be at the planning table.

It is also essential that the many major dimensions of the ambulatory care nurse role, such as advocacy, care coordination, education, quality improvement, and com- munity outreach (Haas, Hackbarth, Kavanagh, & Vlasses, 1995) be built into these new delivery models, because each of these dimensions demonstrates how the ambula- tory care nurse is the “touchstone” for patients and fami- lies seeking and receiving care in ambulatory care settings.

PPACA is expected to decrease the cost of health care over the next 10 years. The major ways that these cost sav- ings will be accomplished are promoting health and prevent- ing disease, decreasing reliance on fee for service, providing cost-effective care, and using the electronic health record (EHR) across settings. Two of the delivery systems highlight- ed in PPACA are the “Patient Centered Medical Home” (PCMH) and the “Accountable Care Organization” (ACO).

PCMHs and ACOs PPACA authorizes states to establish community-based

interdisciplinary or inter-professional teams to support pri- mary care practices within a certain area. The “Health Teams” discussed in PPACA may include nurses, nurse prac- titioners, primary care physicians, medical specialists, phar- macists, nutritionists, dietitians, social workers, and providers of alternative medicine. The Health Team is expected to sup- port patient-centered medical homes, which are defined as models of care that include personal physicians, whole per- son orientation, coordinated and integrated care, and evi- dence-based medicine (American Nurses Association, 2010). Shortell (2010) asserts that in the PCMH “physicians need to develop strong reciprocal referral working relationships” (p. 17) with specialty physicians and a local hospital. Essential also to cost-effective care in the PCMH is use of integrated electronic health records.

ACOs “are organizational structures within which hos- pitals, physicians and others can work together to provide the most cost-effective care and be held accountable” (Shortell, 2010, p. 17) for outcomes achieved. Presumably,

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References American Nurses Association. (2010). Health care reform tool kit.

Retrieved from http://www.nursingworld.org/healthcarereform toolkit

Devers, K., & Berenson, R.A. (2009). Can accountable care organiza- tions improve the value of health care by solving the cost and qual- ity quandaries? Timely analysis of immediate health policy issues. Washington, DC: Urban Institute. Retrieved from http://www.urban.org/UploadedPDF/411975_acountable_care _orgs.pdf

Haas, S.A., Hackbarth, D.P., Kavanagh, J.A., & Vlasses, F. (1995). Dimensions of the staff nurse role in ambulatory care: Part II- Comparison of role dimensions in four ambulatory settings. Nursing Economic$, 13(3), 152-165.

Shortell, S. (2010). Delivery system reform: Accountable care organ- izations and patient-centered medical homes. In The Society for Healthcare Strategy and Market Development (Ed.), Futurescan 2010: Healthcare trends and implications 2010-2015. Chicago, IL: Health Administration Press.

Electronic Health Records With an integrated EHR, patient information is readily

available and easily shared within the entire health team. One of the reasons ambulatory care RNs must be at the planning table when PCMHs and ACOs are being designed, implemented, and evaluated is the need for EHR documentation formats that reflect the work ambulatory RNs are doing in areas of care coordination, monitoring, counseling, and educating complex, chronically ill patients. In the absence of readily available documentation on care coordination done by the ambulatory care RN, costly redundancies in care are likely within this patient population. The EHR will be instrumental to integrated, cost-effective care only to the extent that the entire health team documents and can easily access the documentation of the rest of the team. The EHR also means that test results are available in a timely manner and duplication of testing is avoided.

As health care administrators plan for PCMHs and ACOs, it is critical that ambulatory RNs be involved in the planning and design not only of their role in these new delivery models, but also in the design of the health team; health team communication (both in person and electron- ically); and valid and reliable evaluation tools and methods to track the impact of new care delivery and outcomes achieved.

This column is an overview of PPACA initiatives. Delivery system reform and new care delivery models incentivized by PPACA will be presented and discussed in more depth at the AAACN Annual Conference in April 2011. The conference presentations on new delivery mod- els aim to illustrate the implications of these new models as well as opportunities for ambulatory RNs to participate in their development and be recognized as integral and val- ued for their essential contributions to cost-effective ambu- latory care and patient and family care outcomes.

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at [email protected]

Access and Share Resources in the Document Library AAACN has started a new document library for mem-

bers to share files with one another. Current resources include position descriptions, our project management tool kit, bibliographies, and new assets to help facilities on the journey to achieve Magnet® status. Many thanks to Susan Paschke and her team for assembling the new Magnet® resources!

To access the document library, you must be logged in to your member account at www.aaacn.org. After logging in, click on the link “Document Library” in the lefthand nav- igation bar. The main page of the library lists resource cate- gories and how many files are in each one. By clicking on a category, you will reach its document listing. From here, you can read descriptions and download individual files. Documents are stored primarily in Acrobat PDF or Microsoft Word format, and icons next to each resource will indicate the file type used.

We invite you to share your resources, as well! You can find instructions for submitting a document in the library. If your file doesn’t match one of the categories that cur- rently exist, simply let us know what the new category label should be.

If you find the new document library helpful, let your Board of Directors know. They are responsible for suggest- ing this great resource!

Rebekah Lazar is Manager, Internet Services, American Academy of Ambulatory Care Nursing, Pitman, NJ. She can be reached at [email protected]

Do you have questions about health care reform?

Would you like to share your ideas with others? Join us

on our Health Care Reform forum! AAACN members

are invited to express their opinions, ask questions, and

respond to other members to continue the

conversation about health care reform and how it will

affect ambulatory care nursing.

Visit www.aaacn.org/HCRforum

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