The Evolving Role of Nursing
in ACOs and Medical Homes
Carol A. Conroy DNPc RN CNOR
Chief 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
• Practice in settings across
the continuum
• Focus on inpatient care
delivery
• Focus on high-risk
populations
• High degree of setting
control
• 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
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.
100
Patient/Family
“Control”
The “System”
0
Low
“Acuity”
High
Ref: Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management.
www.aafp.org/fpm. January 2008.
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 selfmanagement.
• 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 Prepared
Clinical Nurse Specialist
UPenn TCN trained
RN
BSN
RN
Setting
All settings across the continuum
Non-SVHC settings (Tertiary care,
nursing homes, patient home)
Single primary care practice
Residence of referred
patients that meet payer
criteria
Population
High-Risk, high utilizers
Complex 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 settings
Identification of high-risk patients
Intensive disease management and
care coordination of individual patients
Research on best-practice and
outcomes
Implementation and spread of
evidenced-based practice across care
setting
Address systemic care transition
process issues
Assessment and risk
identification
Panel management
Population management
Wellness and prevention
Chronic disease
management
Case management
Patient education
Patient goal setting
Assessment and risk
identification and referral
Panel management
Population management
Wellness and prevention
Chronic disease
management
Case management
Patient education
Patient 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
References
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