Accountable Care Organizations

Accountable Care Organizations
Give an introduction using the below article.
The Clinical Nurse Leader: Prepared for an
Era of Healthcare Reform
Brenda Recchia Jeffers, PhD, RN, and Kim S. Astroth, PhD, RN
Brenda Recchia Jeffers, PhD, RN, is Chancellor and Dean, St. John’s College, Springfield, IL; and Kim S. Astroth, PhD, RN,
is Assistant Professor, Mennonite College of Nursing, Illinois State University, Normal, IL.
Keywords
Clinical nurse leader, healthcare
reform, integrated care delivery,
nursing education
Correspondence
Brenda Recchia Jeffers, PhD, RN,
Department of Nursing, St. John’s
College, Springfield, IL
E-mail: Brenda.jeffers@
stjohnscollegespringfield.edu
Jeffers Astroth
PROBLEM. Passage of the 2010 Patient Protection and Affordable Care
Act will require change in the healthcare systems. The clinical nurse
leader must be prepared to lead and shape the changing environment to
achieve maximum outcomes for patients and families. Movement toward
integrated care delivery across the care continuum, the transition of the
Centers for Medicare & Medicaid Services to a value-based funding
model, and accountability for high-quality, cost-effective care are just
some of the drivers of this new integrated healthcare system.
IMPLICATIONS. Reimbursement models that reward those health
systems that are able to meet benchmark performance standards will
result in major shifts in how health systems operate. Expertise in care
coordination across the healthcare continuum is essential for maximum
reimbursement. Payment for value instead of volume delivered is a major
reimbursement transition coming to the acute care setting, necessitating
increased attention to mining data necessary to capture quality patient
outcomes for maximum reimbursement.
CONCLUSIONS. The clinical nurse leader is ideally suited to function
within these integrated systems of the future, and possesses the skills
needed to assist healthcare systems to meet this challenge.
The healthcare system, as we know it, is changing
rapidly. With these changes, the nurse must be prepared
to shape and lead the emerging environment to
achieve the highest outcomes for patients and families.
Some of the drivers of this emerging system are as
follows: (a) movement toward integrated care delivery
across the care continuum, (b) the Centers for Medicare
& Medicaid Services’ (CMS) transition to a new
value-based funding model, and (c) accountability
for high-quality, cost-effective care. Reimbursement
models that reward health systems meeting benchmark
performance standards will result in major shifts
on how health systems operate. The clinical nurse
leader (CNL), a new nursing role introduced by the
American Association of Colleges of Nursing (AACN)
in 2003, is ideally suited to assist healthcare environments
to meet this challenge. The CNL is a master’sprepared
nurse generalist educated with competencies
needed in this new time to assure quality healthcare
delivery. The CNL focuses on safety, quality outcomes,
evidence-based practice, care coordination, advocacy,
and financial stewardship (AACN, 2007). This focus
makes this care provider uniquely prepared to lead
change and high performance across the health
system.
The Institute of Medicine (IOM) report, The Future
of Nursing (2010), challenges the nursing profession, as
well as the entire healthcare system, to examine the
implications of their recommendation that all nurses
work to the maximum extent of their education
and leadership competencies. Examination of the
master’s-prepared nurse generalist educated within
the CNL curricular framework provides an opportunity
to reflect on the graduate competencies, optimal
function, and leadership opportunities for this nursing
role. While the CNL role was designed prior to The
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Future of Nursing report and the passage of the 2010
Patient Protection and Affordable Care Act, IOM
reports, such as the Health Professions Education: A
Bridge to Quality (2003), influenced the development of
the CNL role (AACN, 2007). The recent IOM round
table on the learning health system (IOM, 2011)
articulates that the use of high-quality evidence is
imperative to achieve value-based care delivery within
an improved healthcare system. The healthcare
reform transitions taking place now and anticipated in
the near future resonate with the educational competencies
and role preparation of the CNL. The purpose
of this article is to review major reforms coming to
healthcare systems and to examine the fit of the CNL
role to lead change during a time of system reform and
transition.
Healthcare Reform and Transitions
Creating an integrated healthcare system that performs
as a seamless system and serves the patient is
the goal of major reform initiatives taking place today.
Expertise in care coordination across the healthcare
continuum is essential for maximum reimbursement
for Medicare and Medicaid patients. Integration of
health services and patient-centered medical homes
are two organizational models poised to provide
patients the right health care at the right time in the
right setting with the best outcome. Payment for value
instead of volume delivered is a major reimbursement
transition coming to the acute care setting, necessitating
increased attention to mining the data necessary to
capture quality patient outcomes for maximum reimbursement.
A brief review of these transitions follows.
Integrating the Healthcare System
A major shift in healthcare delivery is the focus on
integrated healthcare services. The concept and definition
of integrated care have been evolving (Cortese
& Korsmo, 2009; Kodner, 2009), and are now the key
strategies to achieve the quality and value imperatives
of the Patient Protection and Affordable Care Act. Provisions
within the Act identify specific strategies to
achieve patient-centered, integrated health care that,
and if achieved, will provide financial incentives to the
healthcare provider. For example, new provisions in
the Act will expand the care coordination in Medicaid
and introduce for the first time care coordination for
Medicare patients (Thorpe & Ogden, 2010). Consequently,
aging clients with multiple but potentially
preventable chronic illnesses will require more strategic
coordination of care both in and out of the hospital.
Health systems are aligning with physicians, and independent
physician practices are aligning practices to
have the optimal opportunity for care coordination
and for providing patients the right care at the right
place (Fisher, 2008). Interprofessional healthcare
teams must work together to assure that when the
individual interacts with the system, healthcare needs
are quickly identified, care is coordinated, and a welldefined,
follow-up process is in place (Thorpe &
Ogden, 2010).
Patient-Centered Medical Homes and Accountable
Care Organizations (ACO)
The healthy home or patient-centered medical
home model provides a coordinated care environment
that assists patients to move through this new integrated
system (Associated Press, 2011; Fisher, 2008).
The medical home aligns with a primary care practice,
is patient-centered and team-driven, and serves to
coordinate patients’ care to receive the most appropriate
care within the most appropriate setting (Cassidy,
2010). The use of electronic health records and the
ability to monitor the clinical outcomes of patients are
a key to making such a coordinated effort a success.
The Patient Protection and Affordable Care Act (2010)
outlines that the goal of the patient-centered medical
home is to use health teams to better coordinate and
manage chronic disease, as well as decrease hospital
readmissions.
The concept of accountability is an important driver
in healthcare reform reorganization. While the ACO
has received much attention, there continues to be a
lack of clarity around the benefits and drawbacks of
becoming a designated ACO (Johnson, 2011). An
ACO is responsible not only for care coordination, but
also for the quality and costs for a particular patient
population (Rittenhouse, Shortell, & Fisher, 2009).
Not all organizations will meet the qualifications for or
desire to become an ACO as volume and attainment of
care benchmarks must both be demonstrated to
qualify for this designation (Johnson, 2011). Additionally,
the final decision regarding if an organization
qualifies to become an ACO is made by the CMS, not
the organization itself. In all cases, accountability
within a high-quality, high-value environment
remains a key component for the health system of the
twenty-first century.
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Reimbursing for Value
A major challenge facing healthcare systems will be
to shift from reimbursement for volume to reimbursement
for high performance and quality outcomes.
Beginning in fiscal year 2013, a percentage of Medicare
reimbursement will be withheld unless hospitals
meet benchmark performance measures in outcomes
and patient satisfaction. The percentage withheld is
expected to increase in the coming years, but at this
time the increase is unknown. Hospitals can earn
monies back when performance is at or above benchmark
(Lloyd, 2011). Measures of care processes,
including clinical measures for surgical and cardiac
care, and patients’ satisfaction with their care experiences
have been designated as the primary value indicators
in fiscal year 2013. Additional value measures,
including efficiency and outcomes, will be tracked in
subsequent years. Measures of patient experiences
include but are not limited to nurse communication,
pain management, communication about medications,
and discharge information. Healthcare analysts
are emphasizing that for hospitals to achieve these
quality outcomes, a focus on assuring reliable measures,
use of evidence-based practice, and skill in care
coordination is needed (Health Care Advisory Board,
2010; Huron Consulting Group, 2011; Lloyd, 2011).
Implications for the CNL Role
The healthcare system changes, and reimbursement
models require increased emphasis on care integration,
care continuity, and delivery of the most effective
evidence-based care for the best value. The integrated
care system requires care providers to possess a
patient-centered focus, and skills in care coordination
and experience in interprofessional team care delivery.
Likewise, the medical home practice may be seen as a
driver for care integration, with one goal being the
decrease in readmissions through interprofessional
care coordination. ACOs and acute care facilities need
care providers who have an understanding of reimbursement
for clinical outcomes, evidence-based care,
and skills in patient-centered care coordination.
How then can nursing best lead the system
to meet these challenges? The following sections
will describe the preparation of the CNL, and outline
why the CNL is a key nursing role possessing the
education and leadership competencies to lead successful
transition in this era of healthcare reform.
CNL preparation, roles, and current documented
impact will be highlighted.
Current CNL Preparation
While undergraduate education for the registered
nurse introduces the generalist to changing healthcare
system challenges, and provides a solid foundation in
many areas, such as evidence-based practice, informatics,
and leadership, the competencies acquired by
the newly baccalaureate-educated nurse are not sufficient
to lead the transformations occurring within
the current system. The nurse prepared at the undergraduate
level is educated to provide direct patient
care to individuals and groups, and to demonstrate
an initial understanding of evidence-based practice
and informatics. However, given the undergraduate
program focus and length, it is not possible to provide
advanced competencies and skills at the level needed
for leading the changing system demands, for
example, advanced health assessment, organization
systems, quality improvement, risk management, and
information management to track patient outcomes.
Graduate preparation and an advanced nursing degree
are needed to prepare the nurse to fully gain these
competencies.
Recently, the AACN released an updated version of
the Essentials of Master’s Education in Nursing. This
document outlines the essential components of a
program granting a master’s degree in nursing. These
essentials provide standards for the master’s level
preparation of the nurse to gain the necessary knowledge
and skills to function as an expert practitioner in
the new healthcare era. The recommended preparation
of the CNL is mirrored in these nine essentials:
science and humanities background, systems and
organizational leadership, quality improvement and
safety, translation and integration of scholarship
into practice, informatics and healthcare technology,
health policy and advocacy, interprofessional collaboration,
clinical prevention, and master’s-level nursing
practice (AACN, 2011). The core curricular elements
of the CNL preparation include content encompassing
the nursing leadership, clinical outcomes management,
and care environment management (AACN,
2007). More specifically, the CNL preparation includes
management of client outcomes within a framework
of evidence-based quality improvement and client
safety. Preparation begins with a solid foundation in
the liberal arts, which allows for the development of
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problem-solving skills, an ability to interpret and
manage data, the use of knowledge to develop critical
thinking skills, and the application of social, economic,
political, and ethical concepts to patient care problems
(AACN, 2007). Other areas included in the education
of the CNL are advanced physical assessment,
pathophysiology, and pharmacology, in addition to
advanced principles of communication, leadership,
quality improvement, risk management, evidencebased
care, information management, and change
theory. The preparation also includes a minimum of
300 clinical hours of immersion learning and practicing
in the CNL role. Ultimately, these educational
components facilitate the CNL student in providing
the care to best meet the needs of a microsystem of
clients. After or near successful completion of an
accredited CNL education program, the CNL student is
eligible to take the voluntary national CNL certification
exam. This exam contains content on areas such
as nursing leadership, clinical outcomes management,
and care environment management (Commission on
Nurse Certification [CNC], 2008). Successful completion
of this exam confers the right to use “CNL” as part
of the nurse’s credentials (CNC, 2008).
Although some expect some overlap between the
role of the CNL and other advanced roles, the CNL is
prepared as a generalist with enhanced knowledge in
pathophysiology, pharmacology, and physical assessment.
The advanced practice nurse, such as the nurse
practitioner, and the clinical nurse specialist (CNS)
typically focus on specific patient populations and
function in an advanced provider role with prescriptive
authority. While the CNS has education in healthcare
systems, the CNL generalist education focuses, to
a greater extent, on the skills needed to succeed in the
era of system reform. The CNL provides and coordinates
care at the point of care, and focuses on microsystem
change and leadership, while the CNS has a
more specialized population focus and works across
the health system (AACN, 2004). The doctorate of
nursing practice (DNP) is expected to be the foundational
preparation for the advanced practice nurse.
While the CNL typically will provide care coordination
for a group of patients at the microsystem level, the
DNP may provide or oversee care from a macrosystem
perspective. For example, the CNL considers patient
metrics on a group of patients in a hospital unit and
will develop quality initiatives to address those metrics
that need improvement. The DNP can be instrumental
in helping implement the successful quality initiatives
throughout the hospital. A DNP may focus on nursing
systems administration, while the CNL is not intended
for nursing management positions. Instead, the CNL is
a patient care-focused leader and has a pivotal role
in coordinating patient care from an interprofessional
team.
Status of the CNL Within Our Current System
Since 2005, there have been over 1,300 graduates
from CNL programs across the country (AACN, 2010).
Lammon, Stanton, and Blakney (2010) indicated that
CNLs can be employed successfully in a variety of
settings, including acute care, rural health care, veteran’s
health care, public health, and home care. There
are some initial data describing the value of the CNL
role with improved client outcomes. For example,
CNL practice in several veteran’s administration (VA)
health facilities has resulted in overall promising
improvement in outcomes such as reductions in
patient falls, hospital-acquired pressure ulcers,
ventilator-associated pneumonia, and cancelled
scheduled surgical procedures (Ott and Walter, 2009).
In one VA system, Hix, McKeon, and Walters (2009)
reported significant improvements in quality indicators
after CNL implementation, including reductions
in inpatient readmission rates, length of stay, patient
falls, hospital-acquired pressure ulcers, and surgical
infection rates. Stanley et al. (2008), examining the
impact of CNL over a 3-month time period, reported
improvements in multiple clinical outcomes in three
hospitals: improvements in patient satisfaction, positive
impact on new nurse retention, decreased length
of stay, and improved care coordination. An increase
in quality for CMS core measures was present across
all case studies. Stachowiak (n.d.) reported outcomes
from a 2-month CNL pilot in a progressive medicalsurgical
acute care unit. Results indicated an increase
in Press Ganey nurse measures and a decreased length
of stay in the 2-month time period. The decrease in
length of stay was reported to provide a savings of over
$100,000. Additionally, the author presented a patient
case study of chronic illness management, which illustrated
a savings of just under $300,000 when a CNL
was coordinating care. Much of the literature offers
case studies and qualitative data to report the impact
and return on investment of the CNL, and the initial
data are promising.
CNL practice partners are commended for their
vision on the use of the CNL to improve client outcomes
in a cost-efficient manner. The quality improvement,
risk anticipation, and financial consciousness in
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Table 1. Features of the Healthcare System Environments Matched With Clinical Nurse Leader
(CNL) Competencies
Features of the changing
healthcare system Key features of the environment CNL competenciesa
Integrated health care • Reimbursement for care coordination in
chronic illness
• Alignment of physicians and acute care
• Patient receives the right care in the right
setting
• Interdisciplinary
• Electronic communication essential for
coordination
Identifies clinical and cost outcomes that
improve safety, effectiveness, timeliness,
efficiency, quality, and the degree to which
they are client-centered.
Uses information systems/materials/
techniques to facilitate clients’ learning
and improve their health outcomes.
Communicates effectively to achieve quality
client outcomes and lateral integration of
care for a cohort of clients.
Assimilates and applies research-based
information to design, implement. and
evaluate client plans of care.
Uses information systems and technology at
the point of care to improve healthcare
outcomes.
Patient-centered
medical home
• Patient-centered
• Primary care focus
• Interdisciplinary team moves patient
through health
system according to needs
Effects change through advocacy for the
interdisciplinary healthcare team and the
client.
Assumes accountability for healthcare
outcomes for a specific group of clients
within a unit or setting, recognizing the
influence of the meso- and macrosystems
on the microsystem.
Properly delegates and utilizes the resources
(human and fiscal), and serves as a leader
and partner in the interdisciplinary
healthcare team.
Accountable care
environment
• Accountable care organizations
• Focus on defined population
• Care coordination
• High volumes
• Tracking outcomes
• Costs and quality
Assumes accountability for healthcare
outcomes for a specific group of clients
within a unit or setting.
Uses information at the point of care to
improve client outcomes.
Synthesizes data, information, and
knowledge to evaluate and achieve
optimal client and care environment
outcomes.
Reimbursement for value • Outcomes determine reimbursement
• Data-driven
• Patient experience metrics
• Tracking clinical processes and outcomes
Implements cost-effective, quality outcomes
that are safe, timely, efficient, and
client-centered.
Participates in systems review to critically
evaluate and anticipate risks to client
safety to improve quality of client care
delivery.
Synthesizes data, information, and
knowledge (e.g., patient satisfaction and
other quality indicators) to evaluate and
achieve optimal client and care
environment outcomes.
Facilitates client care using evidence-based
resources.
Note: aAdapted and/or reprinted from White Paper on the Education and Role of the Clinical Nurse Leader by the American Association of
Colleges of Nursing, 2007, pp. 34–38. Copyright 2007 by the American Association of Colleges of Nursing.
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CNL preparation fit nicely with the challenges of
value-based purchasing. In addition to the length of
stay cost-savings reported with CNL pilots, the reports
of the CNL impact in improving core measures and
Press Ganey nurse measures show promise for acute
care facilities to capture additional Medicare reimbursement
in value-based purchasing. The lateral
integration of care (care coordination), resource management,
and advocacy inherent in the CNL role will
be important in accountability for discharge planning
that can minimize early readmission. The CNL attention
to microsystem data will promote growth on the
use of information technology at a microsystem level
as a means for tracking patient outcomes, the ultimate
measure of the CNL role. Table 1 illustrates some of
the key features of the new healthcare systems and
select competencies of the CNL role that are best
suited to meet the needs of these new systems. More
research is needed to demonstrate the value of this
new nursing role and its impact on outcomes vital to
the demands prompted by healthcare reform.
Summary
The CNL is well suited to take a leading role within
the identified domains of change for and the new
healthcare system. The CNL has a preparation and
focus in several areas that are critical to the successful
transition to the new era of health care. Specifically, the
CNL focus on care coordination across the healthcare
continuum is vital in ensuring efficiency in managing
care for the client. Furthermore, the emphasis on data
management and on the use of metrics to track client
outcomes is critical to ensure cost-effective, quality
client care with appropriate outcomes.
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