LEADERSHIP ASSIGNMENT PART 2

Sheila A. Haas Frances Vlasses

Julia Havey

Developing Staffing Models to Support Population Health Management

And Quality Outcomes in Ambalakny Care Settings

E xecutive Summary ► There are multiple demands and

challenges inherent in establish­ ing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high- performing interprofessional teams and staffing models and electronic documentation sys­ tems that track performance, patients will have more opportuni­ ties to receive safe, high-quality evidence-based care that encour­ ages patient participation in deci­ sion making, as well as provision of their care.

► The health care organization must be aligned and responsive to the community within which it resides, fully invested in popula­ tion health management, and continuously scanning the envi­ ronment for competitive, regulato­ ry, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collab­ orative practice among the inter­ professional team including the patient.

P atient P rotection and Af­ fordable Care Act (ACA, 2010) provisions, such as the expectation all patients will have access to health insur­

ance (regardless of ability to pay and extant prior conditions), pri­ mary and preventive care in a patient-centered medical home (PCMH), care coordination, as well as evidence-based care deliv­ ered by a health care interprofes­ sional team, have created major challenges in terms of design of staffing patterns, methods, and care delivery models. In addition, the Centers for Medicare & Medi­ caid Services (CMS) and other insurance providers have devised incentives for delivery of high- quality care and penalties for care

that does not meet standards. Pay for performance is a quality incen­ tive, while nonpayment for care incidental to occurrence of “never events” in both hospitals and am­ bulatory care are penalties for poor performance.

As health care delivery moves, however slowly, from fee-for-ser- vice where quantity of care reigns, to a “bundled” payment model where quality outcomes are all important, health care systems are now looking at the need to coordi­ nate care across the continuum so they do not lose reimbursement on bundled payments for desig­ nated patient populations. This has led to rapid increases in merg­ ers and acquisitions of hospitals and ambulatory care practices.

SHEILA A. HAAS, PhD, RN, FAAN, is Professor Emeritus, Loyola University Chicago, Niehoff School of Nursing, Chicago, IL.

FRANCES VLASSES, PhD, RN, NEA-BC, ANEF, FAAN, is Professor, Co-Director, Institute of Transformative Interprofessional Education, Loyola University Chicago, Niehoff School of Nursing, Chicago, IL.

JULIA HAVEY, MSN, RN, CCM, is Senior Clinical Application Specialist, Loyola University Health System, Maywood, IL.

NOTE: This project was funded through Health Research and Services Administration Grant #UD7HP26040. Interprofessional-Collaborative Redesign and Evaluation for Population Access to Health (I-Care Path) Vlasses (PD), Hackbarth, Burkhart, Haas (Co- PD/consultant), Kouba, and Michelfelder.

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Table 1. NCQA-Recognized Patient-Centered Medical Home Six Standards

PCMH 1 Patient-Centered Access: Accommodate patients’ needs during and after hours, provide Medical Home information, offer team-based care.

PCMH 2 Team-Based Care: Engage all practice team members by providing Medical Home information, meet cultural and linguistic needs of patients, and offer team-based care.

PCMH 3 Population Health Management: Collect and use data for population management.

PCMH 4 Care Management and Support: Use evidence-based guidelines for preventive, acute, and chronic care management.

PCMH 5 Care Coordination and Care Transitions: Track and coordinate tests, referrals, and care transitions.

PCMH 6 Performance Measurement and Quality Improvement: Use performance and experience continuous improvement.

Practices must meet the following “must-pass” elements to achieve recognition:

1A Patient-Centered Appointment Access

2D The Practice Team

3D Using Data for Population Management

4B Care Planning and Self-Care Support

5B Referral Tracking and Follow-Up

6D Implement Continuous Quality Improvement

SO URCE: NCQA, 2014.

Unfortunately, there is little un­ derstanding of how to merge cul­ tures, values, beliefs, and practice in these newly created systems. There is a reluctance to embrace use of evidence-based practice guidelines and team-based care that is seen as a loss of profession­ al autonomy. Also, there is an amazing lack of communication between acute and ambulatory settings. The best example of this is often the primary care provider does not know a patient has been hospitalized until the patient re­ turns for a primary care visit and tells the provider about the hospi­ talization, at least what is remem­ bered about the hospital visit.

Three of the biggest chal­ lenges in ambulatory care settings are (a) who should be on an inter­ professional team, (b) how can the team deliver care efficiently and effectively especially to patients w ith complex chronic illnesses, and (c) how can outcomes of care be specified and captured. Meth­ ods to assist in establishing inter­ professional teams and models of care delivery by such teams, as well as development of staffing plans for such models in ambula­ tory settings, are suggested in this article. In addition, staffing mod­ els will be discussed using a PCMH as an exemplar, since there are very explicit standards for re­ cognition as a PCMH (see Table 1) (National Center for Quality As­ surance [NCQA], 2014).

Considerations In ambulatory care settings,

staffing should be highly related to the patient population’s prob- lem(s), complexity, and needs; currently ambulatory care is mov­ ing rapidly to population health management, whereas acute care tends still to be focused on the individual. Furthermore, health care needs of patients in ambulato­ ry care are often complicated by social determinants such as edu­ cation level, health literacy, finan­ cial status, level of social support, living situation, as well as mental

health problems that may be inter­ twined with the presence of ad­ diction to drugs and/or alcohol.

The context of care delivery in ambulatory settings differs greatly from acute care. In acute care, hos­ pital-centered health care profes­ sionals provide the care and thus are in control of care 24/7. In con­ trast, in ambulatory, the patient and/or family or significant others provide and control care, while health care providers engage, faci­ litate, educate, and coach patients and families who are caregivers. The focus of care and documenta­ tion in ambulatory settings is the patient encounter. Traditionally, ambulatory care settings specified weekday hours for patient en­ counters with providers in a clinic setting; only recently have ambu­ latory clinics set up evening and weekend hours and some have instituted walk-in clinics. A qual­ itative research study by Kangovi

and colleagues (2013) found pa­ tients’ solutions to waiting for an encounter/visit time, finding trans­ portation, and missing work was a major reason for calling an ambu­ lance and/or going to the emer­ gency department (ED) for what could have been handled in pri­ mary care.

The Institute of Medicine’s Fu­ ture o f Nursing report (2011) rec­ ommends nurses practice at top of their license and be full partners in care w ith other health profes­ sionals. Actually, all professionals practicing in am bulatory care should be practicing at top of their licenses and should be partners to ensure efficient and effective care. In other words, excellent staffing models require a match of areas of expertise of each provider with needs/demands of the population served. For example, in popula­ tions with complex chronic ill­ nesses and multiple comorbidi-

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Table 2. Specific Roles/Responsibilities Competencies

RR1 Communicate one’s roles and responsibilities clearly to patients, families, and other professionals.

RR2 Recognize one’s limitations in skills, knowledge, and abilities. RR3 Engage diverse health care professionals who complement one’s own

professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs.

RR4 Explain the roles and responsibilities of other care providers and how the team works together to provide care.

RR5 Use the full scope of knowledge, skills, and abilities of available health professionals and health care workers to provide care that is safe, timely, efficient, effective, and equitable.

RR6 Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention.

RR7 Forge interdependent relationships with other professions to improve care and advance learning.

RR8 Engage in continuous professional and interprofessional development to enhance team performance.

RR9 Use unique and complementary abilities of all members of the team to optimize patient care.

SOURCE: IPEC, 2011.

Table 3. Advantages of the BOOST® 8 Ps Tool

1. Inclusion of social determinants as predictors in addition to the typical physical and mental health predictors.

2. Risk-specific interventions are suggested for each predictor. 3. An accountability sign-off is included for areas addressed. 4. Inclusion of standardized communication tools such as the General

Assessment of Preparedness (GAP).

ties, evidence suggests pharma­ cists are best prepared to perform medication reconciliation, educa­ tion, and address polypharmacy issues. Although pharmacist team members are needed today, a for­ mula for financial support of such positions with appropriate daily use of skills hasn’t been devel­ oped. Even inpatient support of pharmacy team members for units and oversight of medication admi­ nistration, dosing, etc. hasn’t been financially sustainable.

There is a significant lack of understanding of the importance of developing high-performing in­ terprofessional teams. Each team

member must understand the role and scope of practice of other team members. In 2011, the Inter­ professional Education Collabora­ tive (IPEC) issued a report on the Core Competencies for Interpro­ fessional Collaborative Practice. One of the four competency do­ mains was Roles and Responsibi­ lities (RR). The General Compe­ tency Statement specifies a need for: “knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of the pa­ tients and populations served” (IPEC, 2011, p. 21). Specific RR Com­ petencies are listed in Table 2.

These competencies were to provide standardized content for education and development of future health care providers across the health professions, but they can also be used for development of interprofessional care teams. Developing competency in the roles and responsibility domain should help decrease the blurring of scopes of practice in ambulato­ ry provider roles.

Developing evidence-based stan­ dard communication tools for use within and across interprofession­ al teams across the care continu­ um is essential. The Situation, Background, Assessment, and Re­ commendation (SBAR) technique has become the Joint Commission’s industry best practice for standar­ dized communication in health care. It has been used extensively in acute care to standardize infor­ mation that should be shared bet­ ween providers (Safer Healthcare, 2016). More robust and compre­ hensive standardized communica­ tion tools are now needed to struc­ ture verbal and electronic commu­ nication between providers across all settings.

Strategies for providing quali­ ty care are moving rapidly to a more intense focus on prevention and population health manage­ ment including stratification of patients within populations, so that patients with more complex problems can be matched to ap­ propriate providers and levels of care. The Society of Hospital Medicine (2014) developed Better Outcomes by Optimizing Safe Transitions (BOOST®). The BOOST tool provides eight predictors of readmission. It can be used both for stratification within popula­ tions and to structure and stan­ dardize communication for popu­ lations (see Figure 1; Table 3). The goal of BOOST is to identify high- risk patients on admission and use evidence-based interventions to decrease identified risks and com­ municate risks and interventions. BOOST’S tools “were derived using the best published evidence

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proieS^ss^ Figure 1. ~ ROOST The Assessing Your Patient's Risk

for Adverse Events After Discharge

Risk Assessment: 8P Screening Tool (Check all that apply) Risk-Specific Intervention

Signature of Individual Responsible for

Ensuring Intervention Administered

Problems with medications (polypharmacy - i.e. a 10 routine meds - or high risk medication including: anticoagulants, insulin, oral hypoglycemic agents, aspirin and clopidogrel dual therapy, digoxin, narcotics) □

□ Medication specific education using Teach Back provided to patient and caregiver.

□ Monitoring plan developed and communicated to patient and after­ care providers, where relevant (e.g., warfarin, digoxin, and insulin).

□ Specific strategies for managing adverse drug events reviewed with patient/caregiver.

□ Elimination of unnecessary medications. □ Simplification of medication scheduling to improve adherence. □ Follow-up phone call at 72 hours to assess adherence and

complications.

Psychological (depression screen positive or history of depression diagnosis) □

□ Assessment of need for psychiatric after-care if not in place. □ Communication with primary care provider, highlighting this issue if

new. □ Involvement/awareness of support network ensured.

Principal diagnosis (cancer, stroke, diabetes mellitus, COPD, heart failure) □

□ Review of national discharge guidelines, where available. □ Disease-specific education using Teach Back with patient/caregiver. □ Action plan reviewed with patient/caregivers regarding what to do

and who to contact in the event of worsening or new symptoms. □ Discussed goals of care and chronic illness model with

patient/caregiver.

Physical limitations (patients with decondition­ ing, frailty, or other physical limitations that impair their ability to participate in their own care) □

□ Engage family/caregivers to ensure ability to assist with post­ discharge care assistance.

□ Assessment of home services to address limitations and care needs. □ Follow-up phone call at 72 hours to assess ability to adhere to the

care plan with services and support in place.

Poor health literacy (inability to do Teach Back) □

□ Committed caregiver involved in planning/administration of all general and risk-specific interventions.

□ Post-hospital care plan education using Teach back” provided to patient and caregiver.

□ Link to community resources for additional patient/caregiver support. □ Follow-up phone call at 72 hours to assess adherence and

complications.

Patient support (social isolation, absence of support to assist with care, as well as insufficient or absent connection with primary care) □

□ Follow-up phone call at 72 hours to assess condition, adherence, and complications.

□ Follow-up appointment with appropriate medical provider within 7 days after hospitalization.

□ Involvement of home care providers of services with clear communications of discharge plan to those providers.

□ Engage a transition coach.

continued on next page

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Figure 1 (c o n tin u e d ). T h e 8Ps: Assessing Your P atient's Risk

fo r A dverse Events A fte r D ischarge

Risk A ssessm ent: 8P S creening Tool (Check all that apply) R isk -S pe cific Intervention

S ign atu re o f Individual R e sp on sib le for

E nsuring Intervention A d m in istered

Prior hospitalization (nonelective; in last 6 months) □

□ Review reasons for rehospitalization in context of prior hospitalization.

□ Follow-up phone call at 72 hours to assess condition, adherence, and complications.

□ Follow-up appointment with medical provider within 7 days of hospital discharge.

□ Engage a transition coach.

Palliative care (Would you be surprised if this patient died in the next year? Does this patient have an advanced or progressive serious illness?) “No” to 1 st or “Yes” to 2nd = positive screen □

□ Assess need for palliative care services. □ Identify goals of care and therapeutic options. □ Communicate prognosis with patient/family/caregiver. □ Assess and address bothersome symptoms (i.e., shortness of

breath). □ Identify services or benefits available to patient based on advanced

disease status. □ Discuss with patient/family/caregiver role of palliative care services

and benefits and services available to the patient.

SOURCE: Reprinted with permission from The Society of Hospital Medicine. © 2014

available as well as expert opin­ ion” (Society of Hospital Medi­ cine, 2014, para. 2). The 8Ps BOOST Risk Assessment is not intended to produce a score, but is a checklist of risks that should be identified and addressed to en­ hance the quality and safety of care of complex chronically ill populations.

Most tools do not incorporate social determinants and use pre­ dictive factors, some of which health care providers and health care systems have little control over and, therefore, are of more limited value. While the search for the perfect tool proceeds, one that has social determinant indicators that providers can address, such as BOOST, should be used. It has great potential to be used exten­ sively in all health care settings I for all patients in populations w ith complex chronic illnesses. Kansagara and co-authors (2011) conducted a systematic review of risk prediction models and con­

cluded, “Though most models in­ corporated medical comorbidity and prior utilization variables, few exam ined variables associated with overall health and function, illness severity, or social determi­ nants of health” (p. 1688). And, practical models using patient assessments made in real-time that offer clinical interventions such as BOOST are simple to use, but are yet to be rigorously vali­ dated. Although tools that use only utilization data are not as robust, it should be recognized inclusion of financial risk based on utilization history would be useful as part of an algorithm with BOOST and are included in many of the state-contracted books of business for care coordination identification (see Figure 1).

Today, the provisions in the ACA (2010) have created the need for continuing education and de­ velopment of all providers, espe­ cially those working in ambulato­ ry care settings. The ACA (2010)

fosters involvement of patients in care decisions and use of best evi­ dence-based guidelines to inform care decisions; this is often at odds with the long-held philoso­ phy that providers know best (Wennberg, 2014). In addition, pop­ ulation health management must also be embraced by health care providers. This means all providers need to know how to search for best evidence-based guidelines, have resources for such searches, know how to evaluate the quality and strength of evidence in guidelines and how to implement the guide­ lines for specific populations, and evaluate data generated during their use and sustain their use. There is also the need to develop workflow based on best evidence. This leads to the need for educa­ tion and understanding of use of informatics, so documentation fits w ith workflow and is effective in tracking of processes and out­ comes. Physicians and advanced nurse practitioners were tradition-

130 NURSING ECONOMIC$/May-June 2016A/ol. 34/No. 3

ally educated to think in terms of best practice for the patient seen on a visit; using population health evidence-based guidelines often is not seen as individualized care. This ideation also needs to be add­ ressed before effective evidence- based care parameters can be established. Similar challenges exist with the ACA provisions that promote use of care coordination and transition management.

Care coordination and transi­ tion management (CCTM) is not only recommended by the ACA (2010), but also endorsed by the NCQA as a standard of practice for PCMHs. CCTM is often believed to be a “natural” part of what nurses do, but all interprofessional team members in a PCMH need educa­ tion regarding their role in CCTM in the PCMH. A national study of the role of registered nurses (RNs) in ambulatory care (Hackbarth, Haas, Kavanagh, & Vlasses, 1995; Haas, Hackbarth, Kavanagh, & Vlasses, 1995; Haas & Hackbarth 1995) found nurses did many care coordination activities, but be­ cause documentation by nurses in ambulatory clinics was, and still is rare, their work with care coordi­ nation is invisible. CCTM educa­ tion for RNs in ambulatory care or acute care settings is now readily available. As RNs become care co­ ordinators and transition man­ agers in acute and ambulatory care settings, CCTM competency needs to be assessed at the organization­ al level and through national certi­ fication examination. Electronic health record (EHR) documenta­ tion screens should be developed and used by nurses and other providers doing CCTM so their care processes and outcomes be­ come visible and can be tracked.

Methods for Developing Staffing Models in Ambulatory Care Settings

A two-pronged approach is needed to develop staffing models. In the short term, to get PCMH interprofessional teams and staff­ ing aligned with the NCQA stan­

dards, the following methods can be used. Long-term, data-captur- ing contributions to care processes and outcomes of all team members are essential and the most reliable data can be pulled from documen­ tation. A long-term strategy for such electronic data capture will be discussed at the conclusion of this article.

Initial development of staffing methods and models should begin in potential high-impact popula­ tion health management areas, areas where complex chronically ill patients are cared for will usu­ ally be a first choice. Often this will mean a business plan that identifies patient populations where CCTM by an interprofes­ sional team has the most potential to affect quality outcomes and assist in avoidance of costs by these populations related to use of the ED and readmission to the hospital post discharge in less than 30 days. Therefore, the inter­ professional team: • Uses available data such as

claims data, quality data, ED visit history, readmission his­ tory, and provider “gut check” to select a patient population that requires extensive popu­ lation health management, such as patients with heart failure and chronic obstruc­ tive pulmonary disease, since readmissions in these two populations are considered “never events” and will not usually be reimbursed.

• Identifies and agrees on an evidence-based guideline for population health manage­ ment (e.g., National Guideline Clearinghouse “Heart Failure: Early Recognition and Treat­ ment of The Patient at Risk For Hospital Readmission;” NCQA quality measures for diabetes mellitus).

• Develops workflow docu­ ments based on the guideline chosen and documents roles and activities.

• Recognizes population health management demands not

only specialty care for these populations, but also primary care; the home for this patient population should be a PCMH.

• Recognizes PCMHs should be prepared to provide evidence- based care by a cohesive inter­ professional team; education to enhance team communica­ tion and collaboration may be needed.

• Recognizes acute care nurses moving to practice in or in collaboration with nurses in ambulatory care settings is a major transition and requires orientation and education of the acute care nurse

• Evolves methods of communi­ cation that are a part of daily practice such as team huddles prior to clinic and weekly care conferences.

• Plans for work time and an environment that will support practice and documentation by the PCMH team (e.g., con­ ference rooms, documentation areas, technology sites for phone and video communica­ tion).

• Introduces patient intake tools such as BOOST to identify and stratify patients who will require increased surveillance and communication.

• Develops an “onboarding” strategy and methods such as physician referral, phone calls, and written invitations to engage patients as partici­ pants in CCTM by the inter­ professional team.

• Considers recruiting one or more patients to be members of strategic planning for the PCMH.

• Works with EHR informati- cians to develop screens for documentation of BOOST as­ sessments, interventions, and outcomes, as well as CCTM assessments, processes/inter- ventions, and evaluation of outcomes.

• Works with team members, who traditionally have done

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little docum entation in am bu­ latory settings (RNs) and often have no place to docum ent, to develop new docum entation screens, scheduled tim e and places for docum entation; ex­ pect resistance to this new ex­ pectation of docum entation.

• Prepares all providers in the PCMH to practice within CCTM dim ensions, evaluation of out­ com es th ro u g h d o c u m e n ta ­ tion of CCTM (Haas, Swan, & Haynes, 2014],

• Prepares providers w ho are com m unicating w ith patients via phone, video, and web por­ tals regarding HIPAA, legal, and docum entation require­ ments.

• Develops operational m odels that identify risks and require­ m ents for a health system to function. Porter (1996) asserts that to be successful, organiza­ tional strategy m ust focus on developing processes w ith in systems that are difficult to m atch. In other w ords, devel­ oping care delivery m odels that achieve high-quality pa­ tient-centered outcomes. Kaplan and Mikes (2012) suggest such m odels m ust identify prevent­ able risks, strategy risks, and external risks.

• Develops m ethods to share processes and outcom es of care provided on an ongoing basis. These suggested methods align

w ell w ith the NCQA Standards for PCMH Recognition.

Electronic Documentation: The Key to Tracking Processes and Outcomes in a PCMH

Long-term development of staff m odels requires robust electronic health care software w ith internal architecture th at can accom m o­ date standardized coding such as SNOMED CT. Valid, reliable, and com parable data can only be cap­ tured w hen internationally accep­ ted standardized term inology and coding are employed.

According to the International

Health Terminology Standards De­ velopm ent O rganization (2016), SNOMED CT:

Is the most comprehensive, m ul­ tilingual clinical healthcare tech­ nology in the world. Enables consistent, processable repre­ sentation of clinical content in electronic health records... W hen implemented in software applications, SNOMED CT can be used to represent clinically relevant inform ation consis­ tently, reliably and comprehen­ sively as an integral part of pro­ ducing electronic health infor­ mation. (p. 1)

Other essentials are docum en­ tation software that can capture the types of providers via their signoff in docum entation and a cadre of informaticians w ho under­ stand how to code assessments, processes/interventions, and out­ comes as indicators in SNOMED CT. W ith these requirem ents in place, docum entation data m ining can assist in developing staffing m odels. However, consideration m ust be given to the fact that in docum entation, form needs to fol­ low function and docum entation m ust fit w ith standard workflow. Currently, EHRs are b u ilt to keep docum entation w ith in encounters to stay w ithin encounters. Excep­ tions to this m odel include trans­ plants and cancer treatm ent plans th a t have extensive tre a tm e n t extending over a long time. There­ fore, care coordination needs to straddle both of those docum enta­ tion m odels in a way that provides needed inform ation to those who need it at the point of care w here it is useful and provides data that are tracked over time, especially for com plex chronically ill p o p u ­ lations. From a policy perspective, consideration m ust be given to com plex chronically ill p opula­ tions, such as patients w ith heart failure, COPD, and diabetes. Pa­ tients w ith m ultiple com orbidities have extensive treatm ent plans that w ill continue u ntil death, so

these populations should be ad­ ded to the m odel of related en­ counters just as transplant and cancer populations.

A lthough use of SNOWMED CT and like standardized term i­ nology is nearly universally used for m eaningful use tool certifica­ tion, the norm al workflow of clini­ cians m ust be considered to attach discreet coding to the docum enta­ tion. A ppropriate use of the prob­ lem list w ould go a long way and is the functionality the software is based on, but the reality is nearly all problem lists in health systems are not entirely accurate. A ttach­ ing identifiers to notes and other entries is prem ised on their use. Flow sheet use, w hich is excellent for data capture and m ining, is not used in am bulatory workflows.

Once docum entation screens are created that have SNOMED CT coded sum m ative assessment, pro­ cess, and outcom e indicators for all specified CCTM activities, then docum entation data sets can be m ined to see w hich types of pro­ viders (identified through coding of license type) are doing w hich assessm ents and processes, and the outcom es achieved. The level of contribution can be calculated and m akeup of the interprofes­ sional team can be verified and m odified as needed over time.

Some of the frequently asked questions about nurses and other providers such as pharm acists and social workers doing CCTM are: W hat num ber of patients can they m anage effectively w ith in each patient population? and W hat are the m ost effective processes or in te rv e n tio n s for an id e n tifie d problem during an assessment? Data m ining of the coded indica­ tors in the docum entation data set provides evidence of w h ich inter­ ventions are linked to specific assessm ents and outcom es and how m any patients and encoun­ ters are typically h an d led by a provider w orking w ith patients w ith in a population health m an ­ agem ent stratum . SNOMED CT and data m ining of the relation-

132 NURSING ECONOMIC$/May-June 2016/Vol. 34/No. 3

ships between certain assessments, processes/interventions, and out­ comes can form an evidence- based decision support algorithm. Data mining can also be used to verify work done by RNs doing CCTM where CMS reimbursement is sought. Other advantages to use of SNOMED CT include the ability to compare practice and outcomes across units in one organization and also across organizations. This is especially important in this era of rapidly evolving health systems. There is a need to move to more granular outcome measures be­ yond the more global ones cur­ rently in use (readmission rates and use of EDs).

Conclusions The ACA provisions offer both

opportunities and challenges. If health care administrators estab­ lish supportive physical and inter­ personal health care environ­ ments, and develop high-perform­ ing interprofessional teams, staf­ fing models, and electronic docu­ mentation systems that track per­ formance, patients will have more opportunities to receive safe, high- quality evidence-based care that encourages patient participation in decision making, as well as pro­ vision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully in­ vested in population health man­ agement, and continuously scan­ ning the environment for compet­ itive, regulatory, and external en­ vironmental risks.

All of these challenges require highly competent providers will­ ing to change attitudes and cul­ ture, such as movement toward collaborative practice among the interprofessional team and the patient. Also required is valuing use of standardized evidence- based guidelines for patient popu­ lations. Care planning based on such guidelines should be adapt­ ed to accommodate patient values, goals, and preferences. Attention

and creativity will be required to address social determinants that often hinder patient engagement and participation in the plan of care. High-quality care and out­ comes must be demonstrated by real-time documentation. $

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