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Hello ACOs

Care model creates new opportunities

Monday November 7, 2011
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Released last month, the Centers for Medicare & Medicaid Services' new guidelines for accountable care organizations were a victory for many healthcare professionals dismayed by the original version released in April. Nursing organizations were concerned the original rules, which detailed a new, collaborative healthcare model, excluded advanced practice nurses and limited roles for nursing leadership. Many organizations expressed their concerns in comments to CMS administrator Donald Berwick, MD.

It seems the public outcry was heeded, and many groups, including the American Nurses Association and the American College of Nurse Practitioners, are encouraged by the changes. Some nurse leaders and educators predict nurses will be the key to success for these new programs, which emphasize care coordination, wellness, teamwork and health education — all areas of nursing expertise.

At first "baffled by the lack of explicit recognition [of nurses]," ANA's senior policy fellow Cynthia Haney, JD, pointed out that some parts of the new rules now incorporate entire portions from ANA comments. The association had made the case for providers other than primary care physicians to have major roles in ACOs. Nurse practitioners and clinical nurse specialists are acknowledged as "significant assets" to ACOs for their part in providing quality, cost savings and care coordination, Haney said, and are fully recognized as primary care providers. Nursing leadership, particularly in process improvement and quality assurance, is recognized in the regulation. The new rules also makes clearer the ACOs' need to show commitment to patient-centered, high-quality care, Haney said.

In the know about ACOs
Set to roll out in January under the Affordable Care Act, ACOs are among a number of voluntary models the CMS is using to encourage healthcare professionals to work in teams, offer preventive health services, manage chronic conditions for at-risk patients and improve patient safety, while reducing costs and maintaining quality care. Federally approved ACOs will be eligible to care for Medicare patients. Some private insurance companies also are forming ACOs with physicians' groups and hospitals and will set their own standards.

The basic ACO model starts with a lead group of healthcare providers, usually a physician group. CMS rules also allow rural clinics and federally qualified health centers to lead an ACO, which can include hospitals, specialists and long-term care facilities. Unlike much of the current healthcare system, in which providers make money only when treating sick people, ACOs may reward providers with a share of the cost savings achieved by retaining or improving patient health. Conversely, providers may see financial losses if they don't meet benchmarks in patient outcomes and care coordination, according to the CMS.

ACOs differ from HMOs, their proponents say, because they are led by providers rather than by payers, patients are free to visit care providers outside the organization, and the costs can't be cut at the expense of quality care. The involvement of nursing leadership could prevent ACOs from repeating the mistakes of previous managed care movements, said Catherine Garner, RN, DrPH, FAAN, dean of Health Sciences in Nursing, American Sentinel University in Aurora, Colo. This time, rather than cutting costs by cutting nurses, successful physician and practice groups and hospitals "are going to need that nurse back in the patient environment," she said. "They're going to be the central link to whether ACOs work or not. It really is a time for nursing to step up as these organizations are forming."

On a role
Although ACO guidelines do not specifically spell out nursing roles, most policy experts see nurses' most obvious positions as care managers, educators, hospital transition coordinators, leaders of quality assurance and — for advanced practice nurses — primary care providers.

"There is lots of opportunity for nurses because of what nurses bring to the table," said Cheryl Schraeder, RN, PhD, FAAN, director of policy and practice initiatives at the Institute for Health Care Innovation, University of Illinois at Chicago College of Nursing.

According to Patty Jones, RN, MBA, a healthcare management consultant with the Seattle office of Milliman, an actuarial consulting firm, nurses are the logical choice to help patients navigate barriers to care and to educate them about how to best care for themselves. They already serve as health coaches for patients with multiple chronic illnesses, and they perform discharge and transition planning for those who are hospitalized. Jones predicted these roles will expand in an ACO.

ACOs should be a perfect fit for advanced practice nurses, said Susan Apold, RN, PhD, ANP-BC, ACNP's director for health policy and dean of the Division of Health and Human Services at Concordia College New York in Bronxville. Data repeatedly shows nurse practitioners produce good outcomes for patients in primary care, she said, and ACOs — with their emphasis on prevention, patient education and care coordination — should be natural settings for them. "If we look at outcome-based care, that's even better for us than fee-for-service care," Apold said. "We stand to shine brightly in a system that looks at outcomes."

Pilot project proof
There are three major ways to deliver quality healthcare in a cost-effective manner, said Harold Miller, president and CEO of the Network for Regional Healthcare Improvement and executive director of the Center for Healthcare Quality and Payment Reform in Pittsburgh. These include helping patients to stay well, managing chronic diseases and reducing readmissions to hospitals.

"All of these areas are things where nurses play very important roles, and in many cases more important roles than physicians play," Miller said.

In 2007, Miller worked with the Pittsburgh Regional Health Initiative on a pilot project that reduced hospital readmission rates by more than 40% in a group of patients with advanced lung disease. In his project, Miller concluded nurses were best suited to be care coordinators because "they were the most flexible and broadly trained," particularly for patients with multiple chronic conditions. It makes sense to use nurses in this role rather than using other care professionals because nurses understand medications, patient education, resource management, psychosocial needs and the importance of working with other providers, he said.

During the project, Miller found home visits were very effective among patients with COPD because nurses were able to find obstacles to healthcare they otherwise never would have discovered. He said one nurse found that a patient who had been repeatedly hospitalized with pneumonia was washing his inhaler and storing it wet in a plastic bag. The spacer for the inhaler was covered with black mold.

Wisconsin-based Marshfield Clinic found value in nurse-driven care when it saved $118 million, in part by expanding its 24-hour nurse hotline to include adult and pediatric patients and adding physician-directed, nurse-managed programs for heart failure, high cholesterol and anticoagulation therapy during a five-year demonstration project funded by the CMS.

Because the clinic serves patients in a vast, mostly rural area, much nurse care coordination is done by phone, said Marilyn A. Follen, RN, MSN, administrator at Marshfield's Institute for Quality, Innovation and Patient Safety. Patients come in person to the heart failure clinic where they are seen by nurse practitioners and receive support and education from RNs. The clinic is in the process of hiring 45 RN care coordinators to help with transition planning for hospitalized patients at high risk of being readmitted, Follen said.

Preparing for the future
Judith Lloyd Storfjell, RN, PhD, FAAN, said the University of Illinois at Chicago is getting requests for nurse care managers who use clinical evidence to help coordinate care for patients, including connecting them with resources, communicating with providers and giving wellness information and education on disease processes. Storfjell is professor, associate dean and executive director at the Institute for Health Care Innovation, UIC College of Nursing. A number of nursing schools are adding programs and certifications for care management.

In addition to expanding their education and training, nurses who are interested in being part of an ACO system, or of any outcomes-oriented model, need to work both within their professional organizations and among their colleagues to make their value known, say nurse leaders and policy experts.

"The central focus of an ACO will be on care coordination in a manner that includes both quality and resource use," Jones said. "There are an awful lot of opportunities that nurses are well suited for. Now is the time to figure out where you really have the interest, passion, or excel at something in addition to clinical skills, and develop that more." •

Cathryn Domrose is a freelance writer.

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ACOs at a glance

Government ACOs
Proposed in the Affordable Care Act of 2010 and finalized this October, a federal “accountable care organization” refers to a group of providers and suppliers of healthcare services who work together to coordinate care for Medicare patients. ACOs can begin operating in January 2012, and participation is voluntary.
Participants can create an ACO in one of two ways:
Medicare Shared Savings Program
Providers who work through this model and meet certain quality standards may share in savings they achieve for the Medicare program. The higher the quality of care that providers deliver, the more savings they may keep.
Advance Payment Model
Qualified physician-owned and rural providers participating in the Shared Savings Program may also receive an advance payment for needed investments, such as for new staff or information technology systems. The advance would be deducted from any future shared savings the ACO achieves.
Quality improvement will be judged in five key areas:
1) Patient/caregiver experience of care
2) Care coordination
3) Patient safety
4) Preventive health
5) Care of at-risk populations
ACOs are among several programs created through the Affordable Care Act to promote coordinated healthcare to improve quality and contain costs. Some others include the Bundled Payments Initiative, which encourages providers to work together to coordinate care for patients through a single episode of an illness; the Comprehensive Primary Care initiative, which allows Medicare to join with other payers such as employer-based health plans and Medicaid to strengthen primary care; and the Advance Primary Care Practice program, which helps federally qualified health centers provide more coordinated care and access to primary care for Medicare patients.
Sources: www.healthcare.gov/news/factsheets/2011/10/accountable-care10202011a.html and www.hhs.gov/news/press/2011pres/10/20111020a.html

Private ACOs
Some healthcare organizations are partnering with private insurance companies to create their own ACOs that may choose not to be part of the federal program. CIGNA, Blue Shield and other insurance companies are working with groups of providers — including physician groups and hospitals — in several states to create ACO-model partnerships for improving preventive care, managing chronic illnesses and sharing cost savings. Some of these nonMedicare ACOs serve specific groups, such as state and local employees, but without CMS oversight.
The private, nonprofit National Committee for Quality Assurance recently issued accreditation standards for private ACOs.
For more information, visit www.ncqa.org/tabid/1343/Default.aspx.