Incentives for quality care and a team approach to treatment are two components of a healthcare reform provision that could have a significant impact on the nursing profession.
Many Michigan RNs already are seeing elements of that provision, Accountable Care Organizations, at work at their facilities. Required by the Patient Protection and Affordability Act, ACOs essentially are networks of physicians, nurses and hospitals teaming together to treat patients, while receiving payments based on improving care. This would offer an alternative to the existing fee-for-service system used by Medicare and most private insurers.
Focus on outcomes
“The concept of the ACO continues to evolve,” said Joyce Young, RN, MS, CENP, CNO for St. Joseph Mercy hospitals in Ann Arbor, Livingston and Saline. “But what we do know is that hospital/health system-based physicians, nurses and other care providers must refocus care delivery-linking outcomes to payment.”
Young said care transitions would be key to ACOs, with a strong focus on preventive and post-discharge care as well as acute care. At Saint Joseph Mercy Health System, an emphasis is being placed on the organization of care delivery with the goal of improving safety, quality and affordability of care, Young said. She points to the work Saint Joseph Mercy nurses and other providers are doing to better prepare heart failure patients for discharge and offer a seamless transition to community care providers and services.
“Early engagement of the patient and the patients’ family [and]support system, creation of the ‘experienced adviser’ role which is filled by members of the communities we serve, pre-discharge visits and consultations from home care/extended care nurses, communication hand-offs and clear patient/family-friendly discharge instructions are just some ways nurses are organizing and focusing care delivery in the ACO world,” Young said.
Henry Ford Health System in Detroit began looking at ACO-style models of care well before healthcare reform measures were being proposed. The health system set out to improve readmission rates in 2008, through initiatives such as assessing patients for high risk of readmission, medication reconciliation, and making sure patients in need of home healthcare providers are seen within 48 hours after discharge, said Katherine Scher, RN, CCM, director of clinical integration for the Henry Ford Physician Network. Scher helped develop a medical home model at Henry Ford in 2007 geared toward team collaboration to treat patients holistically.
“When you think about a medical home, you think about all the disciplines that are available in a specific care unit to take care of patients-physicians, physician assistants, nurses with varying roles…” Scher said. “How does this relate to accountable care? You’re talking about different departments and different care delivery systems working together in collaboration to provide optimal care for patients.”
The University of Michigan Health System recently announced saving Medicare more than $22 million by participating in a five-year project that demonstrated the potential benefits of ACOs, according to a news release. The project involved launching several new programs to improve care for University of Michigan Health System patients, including transitional care programs and others focusing on complex care and medical homes, the release said.
Dearborn-based Oakwood Healthcare, which serves metro Detroit and other communities in southeast Michigan, formed an ACO in November 2010, said Barb Medvec, RN, MSA, MSN, NEA-BC, senior vice president and chief nursing officer for Oakwood. How the health system can create a single focus to deliver the most efficient care from the doctor’s office to home or from acute care to home is one of the strategies of Oakwood’s physician-led board.
“There’s always opportunities to improve care and that’s what ACOs can do,” Medvec said. “We’re all working together to be as efficient as possible because if not, we won’t be able to stay in business.”
Heartland Healthcare Center, a skilled nursing and rehabilitation facility in Ann Arbor, already works closely with local hospitals, said Anita Stamatopoulos, RN, director of nursing. ACOs will help to strengthen that relationship, she said. In April, Heartland began examining ways to reduce the rate of congestive heart failure-one of the main causes of hospital readmissions, Stamatopoulos said. The facility already has seen positive results and recently began working with area hospitals to reduce pneumonia a second major cause for readmissions.
“We’re working really hard to decrease [the re-hospitalization rate]now and it’s only getting better,” Stamatopoulos said.
Stamatopoulos expects ACOs to bring prospects for nurses in areas such as case management, risk management and education. From physician offices to home care, nurses will have to be more prepared to treat patients who, under the existing system, might be admitted to the hospital or be hospitalized for longer stays.
“They’re [hospitals]going to be sending those patients out who have higher acuity,” Stamatopoulos said.
The American Nurses Association recently praised federal regulators for expanding RNs’ roles within ACOs. The final rules, issued by the Centers for Medicare and Medicaid Services, include changes based on recommendations from the ANA and other nursing organizations. Among them are that RNs will be recognized as leaders in quality assurance and process improvement initiatives within ACOs, according to an ANA news release.
Nurses’ skills and education are tailored toward the ACO model, which includes quality measures such as patient experience, care coordination and patient safety, preventive health and caring for at-risk populations, said Marna K. Flaherty-Robb, RN, MSN, CNS, chief nursing information officer for the University of Michigan Health System in Ann Arbor.
“Staff nurses and Advanced Practice Nurses are educated and uniquely prepared to establish relationships, understand and coach for self and family care, coordinate care and help patients to manage symptoms and resources,” Flaherty-Robb said. “Nurses are skilled and compassionate in shepherding clients through difficult periods of vulnerability where complex coordination and communication is necessary and outreach may be warranted.”