1

Nurses: Crucial Collaborators Across

the Continuum

Presented By:

Rhonda Anderson RN, DNSc, FAAN, FACHEChief Executive OfficerCardon Children’s Medical Center, Mesa, AZ

South Texas Annual Joint Healthcare ConferenceHealthcare Landscape 2013

San Antonio, TexasJanuary 25, 2013

-

-

-

-

-

2

ObjectivesThe participant will be able to:

• Explain strategic transition plan to move from illness to health.

• Explain role of nurse leader in care coordination.

• Explain purposeful workforce transitioning.

3

Important Implementation Dates

2010 2011 2012 2013 2014 2015 2016 2017

Medicare market basket update reductions

Extends dependent coverage for children up to age 26

High-risk pool established Patient-Centered Outcomes

Research Institute (comparative effectiveness research)

Center for Medicare & Medicaid Innovation

Increased reporting requirements for non-profit hospitals

Ban on physician ownership of hospitals

Medicare Advantage payment cuts begin

Reductions in payments for select readmissions

Bundled payment demonstration projects start

Increased Medicaid payments for primary care

Independent Payment Advisory Board established

Payment adjustments for hospital-acquired conditions

Medicare Commission’s first report to Congress

Medicaid expands to 133% FPL State Exchanges start Individual mandate Employer “play or pay” Medicare & Medicaid DSH cuts

begin

Accountable Care Organization pilot starts

Hospital Value-Based Purchasing begins

Medicare productivity adjustments

Increased physician quality reporting

• Integrative payment modelso Accountable care organizationso Bundled paymentso Health homes

• Quality care / patient safety• Comparative effectiveness• Coordinated care experience• Meaningful use

Health Care Reform – Key Themes

5

What’s an ACO?

An ACO is generally defined as a local health care organization with a network of providers such as primary care physicians, specialists, and hospitals that are accountable for the cost and quality of care delivered to a particular population.

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

6

What’s an ACO?

The purpose is to deliver more efficient and coordinated care that is rewarded with a financial bonus for achieving performance benchmarks set by the Centers for Medicare & Medicaid Services (CMS).

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

7

What’s an ACO?The Patient Protection and Affordable Care Act (PPACA) refers to an ACO as a legal entity that includes both physicians and hospitals, has at least 5,000 Medicare lives under contract, has the ability to pay participants, and includes both Medicare and commercial lives.

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

Four Emerging ACO Models

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

1. Network

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

2. Organized medical group

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

3. Hospital systems

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

4. Collaborative

Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

13

Provider NetworkQuality• Top quality (measured by HEDIS/NCQA/Core Measures, 80% OP)• Coordinated patient experience• Standard models of care (evidence-based where applicable)

Technology• Technology alignment and adoption (EMR, HIE, Portals, BI Tools)

Leadership Culture• High engagement (culture of improvement, learning and accountability)• Physician leadership to drive engagement

Coordinated Care• Sharing of data between all parties to improve care and lower cost• Broad geographic distribution and appropriate specialty accessibility and availability• Coordinated Care

Low Cost Care• Cost effectiveness (clinical and administrative)

(Critical Success Factors)

14

Nursing’s Role

•Quality Management• Care Coordination• Continuum Management• Role Transitions

15

Aligning Payment with Quality:

MEDICAID• Beginning January 1, 2012, establishes a 5-

year ACO demonstration project for pediatric providers to share in cost savings achieved for Medicaid and CHIP.

• Providers would have to participate in pilot for a minimum of 3 years.

MEDICARE• By January 1, 2012, requires DHHS to create

a program that would reward hospitals and physicians (ACOs) that work together to manage patient costs and quality of care to Medicare beneficiaries.

• ACOs can include physicians, hospitals, nurse practitioners, physician assistants and others.

• ACOs would be rewarded for meeting quality of care targets and cost reductions.

• Preference may be given to ACOs already contracting with the private market.

PPACA: Sec. 2706, 3022, 10307

Accountable Care Organizations

16

Aligning Payment with Quality: Health Homes

• Beginning January 1, 2011, creates a Medicaid state plan option that allows a provider or group of providers to be designated as a medical home for enrollees with at least two chronic conditions.

• The health home must have systems and infrastructure in place to provide:o Comprehensive care managemento Care coordination and health promotiono Comprehensive transitional careo Patient and family supporto Referral to community and social services

• The health home may be a free-standing, virtual or hospital-based, community health center, community mental health center, clinic, physician’s office or physician group practice.

• Provides a 90% federal match to state for 2 years.

• Beginning January 1, 2012, creates a Medicare pilot targeting physician and nurse practitioner-directed home based primary care teams.

• Teams are responsible for providing comprehensive, coordinated, and continuous care to at least 200 high-need beneficiaries at home.

• May share savings in excess of 5 percent.

MEDICAID

MEDICARE

PPACA: Sec. 2703, 3024

17

ALIGNING PAYMENT WITH QUALITY:

PAY FOR PERFORMANCE• Beginning October 1, 2012, establishes a Medicare value-based

purchasing program for hospitals that ties a percent of payments to performance on quality measures starting with:

Acute Myocardial Infarction, Heart failure, Pneumonia care, surgery infection prevention, healthcare-associated infections and patient

satisfaction.• In 2014, will include efficiency measures & Medicare spending per

beneficiary• Hospitals rewarded for attainment and improvement on performance.• Incentive funding comes from reductions that apply to all MS-DRGs:

• Individual hospital performance on each measure will be publicly reported.

• Starting March 23, 2012, 3-year demonstration project to test for CAHs, small hospitals, IRFs, psychiatric hospitals, cancer hospitals and hospice.

• Establishes value-based purchasing program for ASCs.

2013 2014 2015 2016 2017

1.0% 1.25% 1.5% 1.75% 2.0%

PPACA: Sec. 3001, 10335

18

ALIGNING PAYMENT WITH QUALITY:

HOSPITAL READMISSIONS• In June 2008, MedPAC recommended that Congress reduce payments to

hospitals with relatively high readmission rates for select conditions.• Beginning October 1, 2012, CMS will adjust inpatient payments for “higher-

than-expected” Medicare readmission rates based on 30-day readmissions for:o Heart Attacko Heart Failureo Pneumoniao In 2015, expands to COPD, CABG, PTCA and other vascular

• Reduction is applied to all DRGs.• Reductions cannot exceed:

• DHHS may expand the policy to include additional conditions.• Readmission rates for certain conditions will be made available to the public.• CAHs are exempt.

2013 2014 2015 and beyond

1.0% 2.0% 3.0%

PPACA: Sec. 3025

19

ALIGNING PAYMENT WITH QUALITY:

PAYMENT BUNDLING

CoordinationQuality

Efficiency

3 Days Prior to

Admission

Inpatient Stay30 Days Post

Discharge

In June 2008, MedPAC made recommendations designed to improve

the efficiency of hospital episodes, such as bundled payments for select services.

MEDICAID

• Beginning on January 1, 2012, establishes a bundled payment pilot program under Medicaid in up to 8 states.

• Focus on episode of care that includes hospitalization and concurrent physician services.

MEDICARE

• Beginning January 1, 2013, establishes a 5-year national, voluntary pilot program for hospitals, physicians and post-acute care providers to improve coordination, quality and efficiency through bundled payment models.

• Pilot program will cover inpatient, outpatient, post-acute care (IRFs, SNFs, HHAs & LTCHs), & physician services.

PPACA: Sec. 2704, 3023, 10308

Post-Acute Bundles

Meaningful Use ACO

Physician Strategy

L3

Value-Based PurchasingQuality

SafetyHAI

F1.1F1.2

●Care Coordination●Case Rates●Utilization●Readmissions

Population HealthAmbulatory Strategy

Patient-Family Engagement

Avatar

Ambulatory Strategy

Fifteen Imperatives for success under accountable care

Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

Physician alignment

Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

1. Focus physician alignment structures on premium partners who share a common vision of success: value creation, not the immediate upside of a transactional liquidity moment.

2. Organize accountable care networks around proceduralists who will comprise the efficient surgical enterprise, and primary care physicians and medical specialists who will operate the effective ambulatory care management network.

3. Develop physician alignment strategies that support joint contracting with all physicians who will be “principals” of your accountable care enterprise.

Clinical transformation

Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

4. Engage stakeholders from multiple levels and sites of care to engineer a dramatically more efficient accountable care enterprise.

5. Begin clinical transformation initiatives within the acute care enterprise to generate returns to address performance risk and fund investments in managing utilization risk.

6. Activate patients under your care by engaging patients in decision-making both during acute events and before acute events occur.

7. Develop an advanced primary care medical home model that supports proactive chronic care and longitudinal patient management.

Payment transformation

Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

8. Synchronize clinical transformations that reduce demand with changes in fee-for-service payments to capture value created and to avoid accepting too much risk too soon.

9. Pilot population management strategies with the hospital’s own self-insured employee base to perfect the clinical model and capture early value created.

10. Implement new payment innovations from the “inside out,” focusing on changes that maximize the profitability of existing businesses to fund investment in longer-term changes in capabilities and incentives.

11. Design a roadmap for payer contracting strategy based on value creation for purchasers rather than the exercise of leverage.

Information-powered health care

Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

12. Maximize physician engagement in performance improvement with investments in technologies that identify improvement opportunities connected to contractual incentives.

13. Re-orient clinical operations around process design and care standardization in order to unlock the full value of greater IT investment.

14. Inform clinical model redesign, population risk assessment, and targeted patient management through sophisticated data analytics and business intelligence.

15. Support population management through investments in technologies that provide remote and virtual access to medical advice and monitoring.

26

What is YOUR piece of the puzzle?

Acute

Care ?

27

Workforce Transformation

• Current acute care mentality

• Transition planning

• Redistribution of clinicians

28

29

~Questions~Thank you