Patricia Pittman
Emily Forrest
Motivation
• How will payment reforms impact configuration
of the workforce in different settings? How will it
affect RNs?
• Focus on Pioneer ACOs as possible signals of
future- highest risk, most experience.
• The black box of implementation includes
workforces changes.
What we know
• In UK, Gemmell et al find P4P drives hiring of nurses
by GPs (2009)
• Abundant evidence that a variety of nurse led models
are cost effective
• Experts predicted changes for nurses under ACOs
(Sochalski and Weiner 2011), but no empirical evidence to
date.
• But some recent studies on PC teams find expanded
role of MAs and limited role of RNs, except in large
clinics (Blash et al 2011, Piekes et al, 2014; Ku et al 2014)
Methods
• Question: Have RN roles changed and if so how?
• Design: Qualitative/ emic perspective.
• Participants: 18 of 32 ACOs responded (representative by
size, location, ownership and pre-HMO status). 16 CNOs, and
where there was none, 1 CMO and 1 Dir of Innov and Pop Health
• Semi-structured interviews: history of ACO, prior use of RNs,
new roles and deployment since ACO, rationale, challenges and
plans.
• Taped, transcribed, narrative analysis.
Size, Ownership, and Integration Status of Pioneer
ACOs in Sample and Universe
Pioneer ACO
Study Sample
(n=32)
(n=18)
Small ACO (1-3 hospitals)
7
6
Medium ACO (4-7 hospitals)
6
2
Large ACO (8+ hospitals or >1,000
19
10
For profit
19
9
Not-for-profit (includes religious
13
9
Integrated health system
26
16
Non-integrated
6
2
SIZE
physicians)
OWNERSHIP
hospitals)
INTEGRATION
Conceptual Framework:
Workforce Configuration or ‘Task Shifting’
(Adaptation of Sibbald et al )
1.
2.
3.
4.
5.
6.
7.
8.
The enhancement with new activities
The substitution of one profession for another
The delegation of tasks to a different worker
Addition of new types of workers
Change in numbers of workers
The transfer of services from one setting to another
The relocation of workers from one venue to another
The use of liaison across settings
The Rationale for Overall Changes
• We recognized in order to be successful ... we need to change
how we do things.
–
–
–
–
“We are shifting away from a volume approach,”
“keeping the patient at the lowest possible point of care,”
“focusing more on patient engagement,”
and “moving to population health.”
• “The focus is on keeping the patient at the lowest possible point
of care, whether it’s at home with nothing, at home with home
care, etc. and as complexity or need increases, (we ask) what’s
the next level of care giver that’s appropriate within that
context? That’s why we are really starting to look at different
roles. I think we’re just at the beginning of this process of using
RNs in new ways.”
The Rationale in Primary Care
•
•
•
Moving away from ‘The old model of relying exclusively on MAs. We’re
moving into a time when almost all practices will have a nurse”. (Jobs)
“As part of moving from physician centric to patient centric care,
everyone had to have a new role… We expanded the role (of the RN)
… we were using them in passive roles (answering phone, taking blood
pressure or accompanying patient to doctor’s office), and now they are
going into more ‘active functions… We carved out a function for the
RN as leader of the clinical team (Enhancement)
“And that’s when we stole some of the inpatient care nurses. Their skill
is assessment, evaluation, triaging and care management.”
(Relocation)
3 New Primary Care Roles
1. Embedded nurse:
17/18 ACO use RNs as “embedded’ in PC team:
(1) an enhanced triaging role, (2) follow up with patients, (3) screening &
medication adjustments. In addition may, (4) RNs may oversee LPNs, MAs
and CHWs , (5) interact with hospital-based transitionalists, and (6) provide
health education services to community leaders and patients outside the clinic
setting. (Enhanced, Delegation)
2. Direct care nurse:
3/18 use nurses for “quick acute” conditions: eg,
UTI and vaginitis, hypertension management, asthma care, titrating of
medications, pediatric developmental checks, BMT (bone marrow
transplantation), SOT (solid organ transplant), diabetes checks, and
hematology & oncology follow-ups.
• 2/18 Freestanding RN clinics to control a) anti-coagulation meds, & b)
pulmonary hypertension. (Substitution)
Primary Care (cont.)
3. Care Coordination: 18/18.
• New: “As we moved to care management, it had to be done by the RN
•
•
•
-there was no question. So system-wide we now have over 30 care
managers.”
More: “The care manager piece is definitely growing… we are building
up our number of professional nurses who can work with those
patients.”
Some CCs at ACO level (Liaison), while others are clinic specific.
Ratios vary radically 1:60 to 1:150 to 1:3000 depending on type of
program and support.
Additional Settings
Hospitals:
• Enhancing Transitionalist Role: “Before, case managers focused on
admissions, the RAC (Recovery Audit Contractor), and discharge planning.
Now, they assess patients, meet with hospitalist team, apply a risk stratification
tool (supervising lay workers), and start the care transition process.”
– Hiring More: 1 RN (w/ support) per 20-90 patients.
• Telemedicine: Delays in licensing physicians across states, led to use
of ICU nurses to support physicians and nurses in critical access
hospitals.
Home and Hospice:
• Teams of NPs, RNs, MAs/CNAs, MSWs, and sometimes
pharmacists do home and SNF visits.
SNFs:
• RN case managers
Implementation Challenges
1. Cultural shifts:
– RNs from HMO to ACO : Leading from behind
2. Management
– ‘Embarrassment of riches’ in CC causing confusion
– Need for nursing leadership across continuum
– Lack of interoperability among members’ EHRs strain RNs with
liaison roles
3. Payers:
– Inability to bill for simple nurse visits
– Hospitals disadvantages by algorithms
4. Educational Institutions:
– Inadequate preparation for pop health, primary care, care coordination and
supervision – new residency programs (as stop gap) planned in some
ACOs.
Summary of Changes by Setting
CHANGES/SETTINGS
ACO
Central
Office
Primary Care Clinics
Rehab
Hospitals
and SNFs
Enhancement of roles with new
activities
Embedded RNs
 Triage, and follow up
 Screening and medication
adjustment
 Educational outreach to community
Substitution of one profession for
another
Substitution for providers for quick
acute conditions
Delegation of tasks
Delegation with supervision to MAs and CHWs
Change in numbers of workers
More nurses for embedded,
direct care and care
coordinator jobs
Transfer of services from one
setting to another
Relocation of workers from one
venue to another
New home visits
Nurses from hospitals moving to jobs in ACO central level, primary care, and home
care
Use of liaison workers across
settings
Partnerships across settings
Home and
Hospice
Care
Nurses as part of teams that
conduct home and SNF visits
Care coordinators from ACO office and primary care
clinics works with hospital transitionalists
Summary Cont.
• All 18 reported enhancement of nurse roles and increase in
numbers for certain jobs.
• Use of Liaison, Substitution, Delegation, and some Relocation
common but not universal.
• Changes mostly in primary care, but also in hospitals, home
care and nursing facilities
• Many management challenges
The Future
• Epilogue: 3 ACOs in sample drop out group, including ACOs that were
concerned about hospital revenue falling. Yet no observable
differences in 3 that left.
• There is evidence of effectiveness of many of these innovations, but
ACOs are testing the ROIs, since so much of RN work is not
reimbursed, including transition/ coordination functions.
• More anticipated: streamlining CC functions, more RNs in
home/hospice/SNFs, new nursing leadership structures outside
hospital, more residencies.
The Research Agenda
• How much is due to shared savings
incentives vs. other ‘historic’ events, eg
penalty programs vs. ‘selection’ issues like
size?
• Similarly, does general belt tightening lead to
“Top of Ed and Lic” task shifting (beyond ACO
incentives) in a post ACA world.