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The CNO and the ACO: An alphabet soup of healthcare reform

Holmes, Aline M. MSN, RN

doi: 10.1097/01.NUMA.0000399810.78038.24
Feature: Specialty Focus Executive Extra

The CNO and the ACO: An alphabet soup ofhealthcare reform

Aline M. Holmes is the senior vice president of Clinical Affairs and the director of the Institute for Quality & Patient Safety at the New Jersey Hospital Association in Princeton, N.J.

Published this month and in future issues, Executive Extra is targeted to senior-level nurse leaders.

Anyone involved in the U.S. healthcare system knows that at the rate the Centers for Medicare and Medicaid Services (CMS) is spending money on healthcare, Medicare will become insolvent within the next 10 years or so. Healthcare spending on hospitals, physicians, pharmaceuticals, and medical devices now consumes more than 1 of every 6 dollars we earn. It's consuming the energy of our federal legislators and other elected officials, and will be one of the key issues in the 2012 presidential election. "The greatest threat to America's fiscal health is not Social Security," President Obama said in a March 2010 speech at the White House, "It's not the investments that we've made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation's balance sheet is the skyrocketing cost of health care. It's not even close."



Dr. Donald Berwick, the current administrator of the CMS, has written and spoken extensively on what he calls The Triple Aim. To improve the U.S. healthcare system, he writes, requires the simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing the per capita costs of healthcare.1 Berwick writes that under the current model of payment for healthcare services, hospitals and providers are rewarded for doing more procedures and filling beds in facilities (otherwise defined as supply-driven care) rather than organizing care around patients and populations (being patient-centric). We focus our attention on what's going on within our facilities rather than asking what's the best care for our community. Isn't it better to focus attention and energy on improving the care of all of the diabetic or heart failure patients in our communities, giving them the tools and resources they need, and engaging them in their own self-care, than have them end up in our facilities needing dialysis, amputations, I.V. medications, ventricular-assist devices, or other invasive procedures?

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What's an ACO?

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted, and then amended later that same month. The goals of the PPACA are to improve the quality of Medicare services by testing a different payment model and evaluating its impact on the quality of care rendered to its beneficiaries. It's obvious that the CMS wants to move from a fee-for-service model of payment to value-based purchasing, a concept that links payment directly to the quality of care provided. Providers would be rewarded for delivering high-quality, highly efficient clinical care, and accountability and transparency would be reinforced through public reporting of certain key clinical measures. The term accountable care organization (ACO) was introduced to describe an entity composed of healthcare professionals in a network, partnership, or group practice arrangement with hospitals, along with post-acute care providers such as subacute, rehabilitation, and home health agencies, that's held accountable for providing care to a defined population and managing that care in an efficient and transparent manner.

The proposed rule for ACOs was released in March 2011, and there was a public comment period through June 6. The CMS will implement the ACO program in January 2012 and anticipates that 75 to 100 applications will be initially approved. There have been a number of concerns raised about some of the proposed regulations, including the two shared savings options, start-up costs, the retrospective assignment of beneficiaries, the large number of quality measures to be collected and the extensive information technology systems needed to gather that data, the requirement to use the CAHPS (Consumer Assessment of Healthcare Providers and Systems) tool to evaluate patients' experience of care, and the multiple legal and regulatory barriers to clinical integration such as various fraud and abuse statutes. We'll have to wait until the final rule is published to see how the CMS and other federal agencies such as the Office of the Inspector General, the Department of Justice, the Federal Trade Commission, and the Internal Revenue Service address these concerns and make revisions.

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What's your role?

But what's the role of the chief nurse executive in an ACO and where should that individual focus attention? The most important areas are the requirements for the promotion of evidence-based practice (EBP), patient engagement, quality monitoring, and reporting and care coordination—all clearly within the realm of nursing practice and clearly areas that the nursing profession should own.

EBP means applying the best available evidence to everyday clinical practice and ensuring that there's a system in place to regularly review and update clinical practice guidelines so that they're current. Nurse executives need to manage that process in their own organizations and strive to ensure that their staff members have the requisite knowledge, skills, and resources to provide quality, efficient care.

Patient engagement is defined in the PPACA as the active participation of patients and their families in the process of making medical decisions, utilizing resources designed to help them make good decisions for themselves and their families. It includes an approach to patient education that takes into account cultural and religious differences, literacy and health literacy, communication styles, and personal values.

Judith Hibbard from the University of Oregon has done extensive research around patient activation and writes that patients who are activated are more engaged in preventive behaviors, healthy behaviors, disease-specific self-management, and information seeking around their chronic illness. She has developed a patient activation measurement system around 13 items, placing individuals in one of four categories that describe increasing levels of activation and can drive educational efforts.2 Given the role of nursing in all care settings to educate patients and their families about how to care for themselves and manage medications and treatments, the nurse executive must actively manage and monitor these processes to provide the best care possible for patients and families in their communities.

Quality monitoring has become a standardized process in most healthcare settings, but ACOs will foster an increased interest in public reporting of quality measures and transparency. There are initially five quality domains that form the basis for determining, benchmarking, rewarding, and improving ACO quality performance: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. ACOs will have to report on all 65 quality measures, and performance thresholds will be set.

ACOs that don't meet the quarterly performance thresholds won't be eligible for shared savings, regardless of what costs of care are reduced. The CMS fully intends to terminate ACOs that are underperformers or that don't comply with the reporting requirement. Although hospitals have had to incorporate the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) into their patient satisfaction survey process, nationally only a very small percentage of private practice providers have implemented this tool into their systems and will need guidance and assistance on implementation and evaluation of the responses. Nurse executives can be an important resource in this quality monitoring component of an ACO given what they've had to do already to support the collection of data, the maintenance of disease management registries, and the design of performance improvement activities.

Finally, the coordination of care across transitions within hospitals or healthcare organizations, between these entities, and between hospital providers and office-based providers is of paramount importance. There are a number of strategies that nurse executives may want to consider for their own organization, including case management of at-risk populations (such as heart failure and diabetes patients), telephonic care management or telemonitoring, or the use of nurses to ensure transitions are accurate, smooth, and safe. Work done by Dr. M. Naylor from the University of Pennsylvania utilizing advanced practice nurses in a care transition process has demonstrated decreased readmissions, improved patient engagement, and improved patient and healthcare provider satisfaction.3

In a statewide initiative, advanced practice nurses working with heart failure patients in New Jersey have begun working with staff in post-acute facilities, such as skilled nursing facilities and home health agencies, to improve physical assessment skills; the managing of patients in their facilities through a better understanding of the disease process; the monitoring of breath sounds and weight, dietary instruction, and medications; and patient rounds with staff in the facility to reinforce the learning. They've also developed clinical practice guidelines with the organizations' medical directors so that the heart failure patient who gains a little bit too much weight over the course of a couple of days can get an extra dose of diuretic and be monitored more closely to avoid the previously all-too-frequent trips to the ED. These advanced practice nurses have recognized that with the CMS beginning to focus efforts around readmissions, the more skills and knowledge they can provide staff in these post-acute facilities, the lesser the chance that these patients will bounce back to the hospital.

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Take-away message? Be involved

There are many ways that the nurse executive can, and should, be involved as the organization -discusses and plans for activity around becoming an ACO. Many of the systems that need to be in place for a successful ACO are clearly within the expertise and knowledge of chief nurse executives. Nursing needs to be at the table when these issues are being discussed and developed. An ACO can't be successful in ensuring high-quality, highly efficient population-based care without nursing involvement at all levels and in all care settings. As organizations design and plan for implementation of an ACO model of care, chief nurse executives must insist on being included in these critical discussions and planning efforts. ACOs are all about high-quality, cost-effective, population-based care; the management of chronic diseases and aging; and the promotion of wellness and health—all within the expertise of professional nursing practice.

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1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769.
2. Hibbard JH. Increasing patient activation to improve health outcomes and reduce costs. Webinar for the New Jersey Hospital Association, October 2010.
3. Naylor MD. Transitional care for older adults: a cost effective model. LDI Issue Brief. 2004;9(6):1–4.
© 2011 by Lippincott Williams & Wilkins, Inc.