Tag Archives: nursing

Measuring performance of skilled nursing facilities

The skilled nursing facility (SNF) industry is an important area for Medicare accountable care organizations (ACOs), Medicare Advantage health plans, and other Medicare programs. How can these organizations appropriately benchmark performance to provide efficient healthcare and reduce spending for SNF services?

Milliman’s Jill Herbold and Anders Larson offer some perspective in their report “Performance of skilled nursing facilities for the Medicare population.” The report highlights several utilization and expenditure metrics for measuring SNF performance. It also explores SNF performance levels across the United States and provides a quantitative assessment of the opportunities to reduce spending for SNF services.

Ambulatory care: Measuring quality and the impact of nursing

Jones-PattyThe shift of medical care from the inpatient to outpatient setting coupled with the emphasis on transformative designed patient-centered medical home models provides measurement challenges and opportunities. The challenges are how to effectively measure quality in this setting given the range of services that are provided—from routine preventive care to complex surgical and invasive procedures. The concurrent opportunity is to measure and promote the role of nurses in providing and leading the care and coordination services that are at the core of ensuring improved patient experiences and outcomes in the outpatient setting.

Table 1: Percentage Share of Inpatient vs. Outpatient Surgeries (1988-2008)[1]

Ambulatory Care  Measuring Quality and the Impact of Nursing

Table 2: Trends in Inpatient and Outpatient Utilization (1987-2007) [2]

Ambulatory Care  Measuring Quality and the Impact of Nursing 2

Professional nursing associations have taken notice of these trends and are accelerating the effort to improve the measurement of both quality and nursing impact in the ambulatory setting. In January of this year the American Nurse Association (ANA), American Nurses Credentialing Center (ANCC), and American Nurses Foundation (ANF) hosted the Ambulatory Measurement Summit. This meeting, and the work leading up to the summit, involved 40 nursing leaders representing stakeholders in national/specialty nursing organizations, payors with delivery systems, measure developers (including Milliman), delivery systems, and payors.

The charge to this group was to come to consensus on five existing measures that warranted further investigation and potential adaptation as an ambulatory nursing measure. Participating in this exercise with this impressive set of nursing leaders representing a wide range of interests, I was struck by several observations:

• There is a clear need to develop outpatient measures that go beyond preventive and chronic care and address other quality concerns. Ambulatory care (especially procedure-based care) involves complex services with risks and consequences that are not well addressed by today’s measures of processes such as immunization and screening rates.
• There is a continued opportunity to pilot new measures of coordination. There is clear recognition that the new value to consumers (and opportunity for nursing) will be the ability of the healthcare system to help them successfully move from one service to another and it will take innovative minds to design these measures.
• It is hard to measure the impact of nursing independent of other factors. As you examine specific measures it is difficult to claim nursing as the driver of performance in that measure but perhaps this serves to emphasize even more that healthcare involves teams and ultimately identify that nursing remains a key part of that team.

At the close of the summit the attendees reached consensus on five nationally endorsed measures, as having high relevance to nursing impact:

1. Medication reconciliation (NQF #0097)
2. Controlling high blood pressure (HEDIS measure)
3. Depression assessment conducted (NQF #0518)
4. Pain assessment and follow-up (NQF #0420)
5. All-cause readmissions (NQF #1768)

The next step will be for the ANA and the National Database of Nursing Quality Indicators® to undertake further review of the five consensus measures for possible refinement and testing for use within the ambulatory setting. We will watch this initiative closely as we refine Milliman’s measurement tools to fully reflect the changes underway in the healthcare system, as well as the role of stakeholders such as the nursing profession, and to improve the ability to measure the impact of these changes.

[1] Frakt, Austin (October 2010). Inpatient vs. outpatient surgeries. The Incidental Economist. http://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries
[2] Johnson, Tracy K. (May 2010). Ambulatory care stands out under reform. Healthcare Financial Management. http://www.hss-inc.com/healthcare-report/ambulatory-care-stands-out-under-reform.pdf

This article first appeared at Milliman MedInsight.

ACOs enhance career opportunities for nurses

Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) may provide nurses with greater career options. In this Nurse Zone article, Milliman’s Patty Jones discusses some new roles opening up for nurses skilled in care coordination and data analysis.

Here is an excerpt:

“Accountable care and a lot of the initiatives coming out of health reform provide some interesting and new opportunities for nurses,” said Patty Jones, RN, [MBA], a principal at Milliman, a consulting and actuarial firm in Seattle, adding that the positions will take advantage of skills nurses already have and necessitate some to develop new talents.

…“For an accountable care organization to be successful, they are tasked with coordinating the needs of a member or a patient over a series of services and different levels of care over the course of time,” said Jones, explaining that efforts will focus on case managing smoother transitions between settings and ensuring the patient takes prescribed medications and follows through with appointments to avoid re-hospitalizations.

“This is a natural place for nursing and nurse leaders to use skills in terms of care coordination and assist the patient to reach out and get attached to other levels of care,” Jones said.

Newer emerging roles, Jones said, involve patient education and engagement. But the teaching must take place within the framework of the patient’s readiness to learn and motivation for changing to a healthier state.

“It’s a coming together of the science and psychology of nursing,” Jones said.

A third area of opportunity for nurses involves resource management at the patient and organization level, not something all nurses are skilled at or interested in.

“There are real opportunities for clinical leaders, nurses included, to be part of the financial and resource management discussion,” Jones said.

Additionally, nurses will need a population view, similar to a public health approach, to identifying and closing gaps in preventive care. However, it will require an analytic mind and comfort with data.

For more perspective on how healthcare’s changing landscape is affecting nursing professionals, click here.

Are health plan nurses measurably ready for the future?

The innovations and opportunities resulting from healthcare reform—accountable care organizations (ACOs) and patient-centered medical homes—rapidly expand the roles of nurse care managers. These models require population-based analysis and prioritization, proactive care gap closure and care coordination, and credible assessment of impact to determine if cost and quality are improving.

At the core of all these models and the transformative direction of health reform, are key design principles that include:

• Population-based analysis used to target and prioritize interventions
• Accountability for achieving quality and financial goals for defined populations
• Patient-centered care design that addresses medical as well as psychosocial needs
• Education and engagement strategies that directly involve the patient and family in achieving better health and preventing exacerbation of chronic care
• Medical homes and medical “neighborhoods” that integrate primary care, specialty care, and community programs in a manner that provides better resource use and easier access
• Care coordination that assists patients as they maneuver the complexities of the healthcare delivery system
• Proactive outreach that encourages timely preventive care and supports care compliance
• Transparent discussions and thoughtful choices made based on evidence-based options and costs of alternatives

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A toolkit for healthcare reform: What role will nurses play?

Some have anticipated a shortage of healthcare providers in the coming decades as the U.S. population ages. With that in mind, the Alliance for Health Reform has produced a toolkit focused on “nursing, the coming shortages, how [shortages] might be avoided, and how health reform is contributing to the changing role of nursing.” The following excerpt provides context:

Currently there are about 3 million licensed registered nurses in the United States. Most, about 60 percent, work in hospitals. Almost 266,000 are advanced practice registered nurses (APRNs).

It is projected that 260,000 additional nurses will be needed by 2025 to care for the increased population, the increase in insured population and the explosive care needs for chronic diseases in the population and geriatric care in older age groups.

Several factors are thought to contribute to the projected shortage in nursing. These include a decline in RN earnings relative to other career options, an aging nursing workforce, job dissatisfaction among nurses, and an aging, sicker population that will require more intense health care services.

An October 2010 report by the Institute of Medicine recommended that nurses be allowed to practice to the full extent of their education and training, yet scope of practice laws vary from state to state. Is the time right for states to update these laws to mitigate the shortage of providers especially in primary care and especially in rural areas?

Among the resources provided in the toolkit is Patty Jones’ paper entitled “The Nurse’s Role in Accountable Care,” which considers the important role registered nurses will need to fulfill if accountable care organizations (ACOs) are going to be successful under healthcare reform. Here is an excerpt from her paper:

Nurses currently work in a variety of organizations likely to be involved with [ACOs], including practitioner offices and clinics, hospitals, insurers, and community health organizations. As a result, they often are in a position to help address one of the key needs of accountable care: improving care delivery and coordination across a variety of settings and types of care.

…Most organizations will need to take stock of their current resources, fill in gaps, and re-engineer their process. Most can leverage their current resources and help ensure the success of their program by accurately assessing and augmenting the skills of their nursing staff.

Will ACOs accelerate acceptance of nurses as primary care practitioners?

An editorial in The Atlantic recently argued strongly in favor of the expansion of the role of nurses in primary care:

Should the ACA pass muster with the Supreme Court next month, an additional 30 to 33 million previously uninsured Americans will be covered — and even if ACA is not implemented in full, and in the end merely expands Medicaid, it will add 17 million to the insured ranks by 2020.

One of the best ways to alleviate this shortage is to expand the scope of practice for advanced practice registered nurses (APRNs), well-trained registered nurses with specialized qualifications who can make diagnoses, order tests and referrals, and write prescriptions. APRNs could provide a variety of services that primary care physicians now provide.

This issue remains contentious, but one of the most interesting points the author made concerned a frequent topic of this blog—the growth of accountable care organizations (ACOs):

Employers and patients are beginning to clamor for progress in this area and the turf wars may lose steam as we move away from fee-for-service and toward accountable care organizations, in which a team of providers takes responsibility for the well-being of a population in return for global rather than provider-specific payments.

A 2011 article on Gannett’s Nurse.com on the role of nurses in federally sanctioned ACOs referenced Milliman’s own Patty Jones on the topic:

According to Patty Jones, RN, MBA, a healthcare management consultant with the Seattle office of Milliman, an actuarial consulting firm, nurses are the logical choice to help patients navigate barriers to care and to educate them about how to best care for themselves. They already serve as health coaches for patients with multiple chronic illnesses, and they perform discharge and transition planning for those who are hospitalized. Jones predicted these roles will expand in an ACO.

You can read Patty’s paper on the topic of nurses in accountable care here.