NONPF Presentation: April 2011p

Preparing NPs for Leadership and Practicein Health/Medical Homesin Health/Medical Homes

and Accountable Care Organizations

Linda L. Lindeke PhD RN CNP FAAN Director of Graduate Studies ecto o G aduate Stud es

Mary Chesney, PhD, RN, CNPDirector of Doctor of Nursing Practice (DNP) Program

School of Nursing, University of Minnesota

Presentation Message #1:Presentation Message #1:

Being an expert NP clinician is not enoughBeing an expert NP clinician is not enough in this climate of urgency 

to improve the quality and 

cost effectiveness of health carecost effectiveness of health care 

and to demonstrate effective care toutcomes.

Presentation Message #2:Presentation Message #2:

NP educators must create learningNP educators must  create learning materials & experiences 

to ensure that graduates 

are fully prepared for leadershipare fully prepared for leadership 

in evolving models of care delivery, ifi ll i H th/M di l H dspecifically in Heath/Medical Homes and 

Accountable Care Organizations (ACOs).

IOM’s Key MessagesIOM s Key Messages #1) Nurses 

• Need to remove  scope‐of‐practice restrictions for 

should be able to 

i APRNs• Need nurse residency program 

practice to full extent of 

th iy p g

to better manage transition from school to practice

their education d t i iand training

IOM’s Key MessagesIOM s Key Messages

• Foster#3) Nurses  • Foster leadership skills and 

i

should be full partners with 

competencies• Nurses must see policy as

physicians and others in 

d i i policy as something they shape 

redesigning U.S. health 

carecare

Nursing: Scope and Standards of ” ( )Practice” (2010)

An APRN or graduate‐level prepared specialty nurse “provides leadership in the coordinationnurse  provides leadership in the coordination of interprofessional health care for integrated delivery of healthcare consumer caredelivery of healthcare consumer care services” (p. 40)

DNP Essential II (AACN 2006 )DNP Essential II (AACN, 2006 )

Organizational and Systems LeadershipOrganizational and Systems Leadership for Quality Improvement and Systems Thinkingand Systems Thinking

“Develop and evaluate care delivery approaches that meet current and future needs of patientthat meet current and future needs of patient populations based on scientific findings in nursing and other clinical sciences, as well asnursing and other clinical sciences, as well as organizational, political, and economic sciences” (p. 9)

HC Reform Framework Driving New d l f l bModels of Delivery & Reimbursement

• Improve population health

• Enhance consumer experience

• Reduce/control costsReduce/control costs

Berwick DM Nolan TW &Whittington J (2008)Berwick, DM, Nolan, TW, & Whittington, J. (2008)

HCHs & ACOs: Integrated Health SystemsHCHs & ACOs: Integrated Health SystemsTeam-modules of coordinated, patient-family-centered care

Responsibility & risk-sharingfor population of patientsp p p

New outcome-based,New outcome based, risk-adjusted

payment models

What Are Elements of an Integrated l hHealth System?

• Family‐Centered – Patient/family at center of care planningy / y p g

• Shared Quality Goals– Clinical outcomes

R d d i ti i i d li– Reduced variation in service delivery

• Shared Fiscal Accountability Across all Stakeholders

• Patient Receives the Right Care at the Right Time in the Right g g gPlace

• Value= quality/ cost per unit time

• IOM Quality:  STEEEP

• Health Information Technology

Primary Health Care Home ModelPrimary Health Care Home Model

• Includes integrated system attributesIncludes integrated system attributes

• PHCH has defined population of patients; payment (eventually) based on outcome measures of ( y)population health

• Payment model drives process improvement‐leading y p p gto most effective, efficient, cost‐effective care

• Capitation with risk‐adjustment based on morbidity & social determinants

• PHCH entity assumes benefits, risks, & accountability 

Accountable Care OrganizationAccountable Care Organization

• Level 1 ACO: Primary care practices functioning together through an IPA• Level 1 ACO: Primary care practices functioning together through an IPA 

• Level 2 ACO: Primary care practices and frequently‐used specialties, working together through an IPA or multi‐specialty group practice

• Level 3 ACO: Primary care practices, specialists, and hospitals, working together through an integrated delivery system or other organizational mechanism

• Level 4 ACO: Healthcare providers, public health agencies, and social service organizations working jointly to improve out‐comes for a very broad patient population, including homeless individuals and the uninsured

Miller, H. (2009). How to Create Accountable Care Organizations (1st Ed).  Center for Healthcare Quality and Payment Reform, (pp 18‐19).  Retrieved @ http://www.createhealthcarevalue.com/data/blog/HowtoCreateAccountableCareOrganizations1.pdf

Key Elements of Accountable Care Model

• Local Accountability• Local Accountability• Foster provider accountability for quality and per capita cost for their patient population

• Standardized Performance Measurement• Increased accountability on the part of providers should be accompanied by improved incentives and information for consumers

• Payment Reform• Transition payments from rewarding volume/intensity to increasing valuep y g / y g• Payments should encourage collaboration and shared responsibility among providers and consistent incentives from payers

NP PHCH/ACO Patient‐Family‐Level Competencies

• Provides appropriate visits and care coordination interactions for complex situations

• Integrates critical information in ongoing manner• Completes/analyzes assessmentsp / y• Develops care plans with families• Manages/tracks tests, referrals, and outcomes

C h ti t /f ili• Coaches patients/families • Supports/facilitates care transitions• Facilitates family & care team meetingsy g• Effectively uses health information technology

NP PHCH/ACO Systems‐Level Competencies

• Develops EB Practice Guidelines & ProcessesDevelops EB Practice Guidelines & Processes

l d l• Develops and evaluates process improvements

• Articulates important roles of NPs and other pAPRNs across systems

Clinically‐Enhanced Starter SetCategory I: Diabetes Category III: Chronic Heart FailureCategory I: Diabetes• HbA1C Control • LDL Control • BP Control 

Category III: Chronic Heart Failure• Beta‐blocker with LVE< 40%• BP Control• LDL Control 

• Eye Exam• Kidney Disease Screen• Aspirin Prophylaxis

Category IV: Hypertension• BP Control 

Category II: Coronary Artery Disease• LDL Control • Aspirin Prophylaxis

Category V: Care Coordination• Tobacco Use Inquiry or Counseling• Childhood immunization• BMI recorded• Influenza vaccine• Pneumovax vaccine• Medication reconciliation• Medication reconciliation

NCQA

P PStandard 1: Access and CommunicationA. Has written standards for patient access and patient

communication**B. Uses data to show it meets its standards for patient

access and communication**

Pts

45

9

Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety

checksC. Has electronic prescription writer with cost checks

Pts33

2

8

Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly

non-clinical data) B. Has clinical data system with clinical data in searchable

data fields C Uses the clinical data system

Pts

2

33

64

Standard 6: Test Tracking A. Tracks tests and identifies abnormal results

systematically** B. Uses electronic systems to order and retrieve tests

and flag duplicate tests

Pts7

6

13

St d d 7 R f l T ki PTC. Uses the clinical data system D. Uses paper or electronic-based charting tools to

organize clinical information**E. Uses data to identify important diagnoses and

conditions in practice** F. Generates lists of patients and reminds patients and

clinicians of services needed (population management)

4

3

21

Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic

system**

PT4

4

Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance

by physician or across the practice**

Pts

3

clinicians of services needed (population management)

Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines for

three conditions **B. Generates reminders about preventive services for

clinicians

Pts3

4

35

by physician or across the practiceB. Survey of patients’ care experienceC. Reports performance across the practice or by

physician **D. Sets goals and takes action to improve

performance E Produces reports using standardized measures

33

3

21

C. Uses non-physician staff to manage patient careD. Conducts care management, including care plans,

assessing progress, addressing barriersE. Coordinates care//follow-up for patients who receive care

in inpatient and outpatient facilities

5

20

S d d 4 P i S lf M S Pt

E. Produces reports using standardized measures F. Transmits reports with standardized measures

electronically to external entities 15

Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification

Pts121

Standard 4: Patient Self-Management Support A. Assesses language preference and other communication

barriersB. Actively supports patient self-management**

Pts24

6

C. Electronic Care Management Support4

Children’s Hospital Boston Integrated Care System

Care Plan ElementsCare Plan Elements

Medical Home Practice Care Plan

Problem Activity Who will do By When Expected Outcome Follow-Up

Prepared for:  Primary Care Provider   PCP:           Prepared by: Care Coordinator    Date Plan Prepared:    

.

Jointly Created Care Plan

• Integrated into Health Record

• Map to services– Work in progress

– Updated on an ongoing basis

Collaborate with families to ensure satisfaction– Collaborate with families to ensure satisfaction

– Approved by primary care and specialist physician

– Shared with community partners, upon consent of family

Palfrey (2004):d l d

• For about $400 per child per year parents

Medical Home Study For about $400 per child per year, parents reported:– Better access to needed services (i e– Better access to needed services (i.e. prescriptions, primary & specialty care, referrals, equipment)q p )

– Improved understanding of their child’s condition by MDs & Staff

– Significant reduction in child hospitalizations 

– Fewer parental days lost from workp y

Nursing Roles & Opportunities:

Dynamic time for nurses to:

Nursing Roles & Opportunities:

Dynamic time for nurses to:

• Advocate for vulnerable populations• Advocate for vulnerable populations

• Join coalitions with health leaders, professional i ti it i tiorganizations, community organizations

• Become board members (local, state, regional ti l)national) 

• Publish! Present! Lead! Consult!