The Evolving Role of Nursing in ACOs and Medical HomesCarol A. Conroy DNPc RN CNORChief Nursing Officer/VP Operations

VONL SUMMIT: April 19, 2013

The Care Span: The Significance of Transitions

• Transitions: Handovers are vulnerable exchange points that contribute to unnecessarily high rates of health services use

• 2009 study reported 20% of Medicare beneficiaries discharged from hospitals were re-hospitalized within 30 days; 34% within 90 days.

• 13% of Medicare beneficiaries experience 3 or more provider handovers during a 30 day period

• Patient “churning” accounts for $15 billion in annual Medicare spending

• Transitional Care is a broad range of time-limited services designed to – ensure health care continuity– avoid preventable poor outcomes among at-risk populations– promote the safe and timely transfer of patients from one level or

type of care setting to another

Hallmarks of Transitional Care• Focused on highly vulnerable, chronically ill

patients throughout critical transitions in health and health care

• Considers the time-sensitive nature of services

• Emphasizes the education of patients and family care-givers

• Compliments, but not the same as primary care, care coordination, discharge planning, disease management and case management

What Patient-Centeredness Should Mean• Power and control shifts into the hands

of patients, families, and communities

• Status quo: the cathedral of care is the hospital and health care professionals are the “hosts”

• New order: health care professionals are guests in the patients’ lives

Clinical Nurse Specialist (CNS)Role Redesign

• Acute Care Based

• Focus on inpatient care delivery

• High degree of setting control

• Practice in settings across the continuum

• Focus on high-risk populations

• Patient self-management and shared decision making

CNS Role Re-design

• Re-engineered an existing resource to address the needs of patients at high-risk for failure after discharge

• Shifted the focus to high risk populations across multiple care settings or the patient home

Low

0

High

100

Who really Controls Outcomes?

The majority of health care occurs at the low-acuity end of the scale, where outcomes are controlled not by physicians or “the system” but by the everyday choices of individuals and families, which are strongly influenced by their values, culture and communities. The largest opportunity clinical staff have to influence health outcomes is to influence choices by partnering over time.

Ref: Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. www.aafp.org/fpm. January 2008.

“Control”

“Acuity”

Patient/Family

The “System”

Key Concepts • Patient/Family control. Think of low acuity as being the

home setting and high acuity being the intensive care unit. The patients lifetime of “Health” management occurs in the low acuity setting where the patient makes their health decisions.

• New skills for nursing in the low acuity setting include shared decision making, patient goal setting and self-management.

• The medical home provides the environment for the application of these skills

• The CNS identifies and assists the patient to manage risks during complex care transitions and facilitates exquisite coordination of handovers.

Element Transitional Care Nurse (TCN) Blueprint Case Manager Home Health Nurse

Education Masters PreparedClinical Nurse Specialist UPenn TCN trained

RN BSNRN

Setting All settings across the continuumNon-SVHC settings (Tertiary care, nursing homes, patient home)

Single primary care practice

Residence of referred patients that meet payer criteria

Population High-Risk, high utilizersComplex patients with multiple providers or settings of care No payer referral required

Primary care practice population

Only home bound patients that meet payer criteria

Key Functions

Coordination and collaboration across multiple providers and care settingsIdentification of high-risk patients Intensive disease management and care coordination of individual patientsResearch on best-practice and outcomesImplementation and spread of evidenced-based practice across care settingAddress systemic care transition process issues

Assessment and risk identification Panel managementPopulation managementWellness and prevention Chronic disease managementCase management Patient educationPatient goal setting

Assessment and risk identification and referral Panel managementPopulation managementWellness and prevention Chronic disease managementCase management Patient educationPatient Goal setting

Service Duration

Time limited (8-12 weeks per patient)

The duration a patient is member of primary care practice panel

Intermittent short episode of care. Number of visits limited

Challenges to the CNS role redesign

• Shift away from acute care focus to the continuum of care

• Staff training and role redefinitions

• Avoid duplication of services

• Patient navigation across multiple, complex medical settings

• Patient/family directed care

CNS Redesign Strategies

• Orientation to transitions across the continuum

• Identification of high-risk patients

• Focus on the patient not the disease

• Use of Patient self-management tools

• Use of Shared decision making

• Transitions Team includes community partners

• Communication with the primary care practice teams in medical homes

• Formal education in partnership with UPenn

American Academy of Nursing. (2012). Policy Brief 3.5.12. The Imperative for Patient, Family and Population Centered Interprofessional Approaches to Care Coordination and Transitional Care.

ANA. (2012). White Paper: The Value of Nursing Care Coordination

Berwick D. “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist” Health Affairs, July 19, 2012

Brock J, Mitchell J, Irby K, Stevens B, Archibald T, Goroski A, Lynn J. “Association Between Quality improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries.” JAMA, 23/30, Vol 309, No.4, 2013

Clavelle J. “Implementing Institute of Medicine Future of Nursing Recommendations: A Model for Transforming Nurse Practitioner Privileges.” JONA, Vol. 42, No.9, 2012

Goodman DC, Fisher E, Chang C,. “The Revolving Door: A Report on US Hospital Readmissions.” Robert Wood Johnson Foundation/The Dartmouth Institute; 2013 Naylor MD, Aiken LH, Kurtsman ET, et al. “The Care Span: The Importance of Transitional Care in Achieving Health Reform.” Health Affairs, 304(4): 746-754, 2011

Sherman RO. “Lessons in Innovation: Role Transition Experiences of Clinical Nurse Leaders.” JONA, Vol. 40, No. 12, 2010

References