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 services 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 community outreach (Haas, Hackbarth, Kavanagh, & Vlasses, 1995) be built into these new delivery models, because each of these dimensions demonstrates how the ambulatory care nurse is the "touchstone" for patients and families 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 savings will be accomplished are promoting health and preventing 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 highlighted 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 primary care practices within a certain area. The "Health Teams" discussed in PPACA may include nurses, nurse practitioners, primary care physicians, medical specialists, pharmacists, nutritionists, dietitians, social workers, and providers of alternative medicine. The Health Team is expected to support patient-centered medical homes, which are defined as models of care that include personal physicians, whole person orientation, coordinated and integrated care, and evidence-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 hospitals, 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 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 payment mechanisms - full capitation, partial capitation, 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:
- Care for patients across the continuum of care, in different institutional settings as well as the home
- Plan, prospectively, for budgets and resource needs
- Effectively use evidence-based protocols and comparative effectiveness research
- Develop and support comprehensive, valid, and reliable 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 preventable readmissions through better coordinated care; and reduce unnecessary and costly use of hospital emergency rooms. The hospital business model shifts from maximizing inpatient care margins 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, especially 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/electronic 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.
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 electronically); 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 models 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 valued for their essential contributions to cost-effective ambulatory 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 firstname.lastname@example.org
American Nurses Association. (2010). Health care reform toolkit. Retrieved from http://www.nursingworld.org/healthcarereformtoolkit
Devers, K., & Berenson, R.A. (2009). Can accountable care organizations improve the value of health care by solving the cost and quality 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 IIComparison of role dimensions in four ambulatory settings. Nursing Economic$, 13(3), 152-165.
Shortell, S. (2010). Delivery system reform: Accountable care organizations 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.