Value-Based Care

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders develop enhanced skills transform in 2020. Key drivers for success include: igniting innovation and change; embracing data analytics; launching new delivery models that soar beyond organizational boundaries. Value-based is here stay, nursing must be catalyst change. Equipped with knowledge of CMS Pay Performance programs, will design future landscape. Points•As movement pushes forward; has unique opportunity align tenets healthcare reform lead this clinical transformation.•Nurses, leadership frontline staff, embrace innovations support Triple Aim, cultivate a vision spans interdepartmental boundaries, extending bricks mortar acute care.•The journey been set; take seat at table as blueprint drawn. •As As part spotlight on value-based (VBC) mandated by Affordable Care Act (ACA) 2010, Centers Medicare & Medicaid Services (CMS) introduced 3 programs reimburse hospitals based value. These pay performance or include Hospital Value-Based Purchasing (HVBP), Readmissions Reduction Program (HRRP), Hospital-Acquired Conditions (HACRP).1Brooks J.A. Reducing hospital readmissions.Am J Nurs. 2015; 115: 62-65Crossref PubMed Scopus (1) Google Scholar,2Brooks The hospital-acquired condition reduction program.Am 2017; 117: 63-66Crossref Scholar focus quality services rendered rather than provided. was developed response unsustainable escalation costs, poor outcomes, shifting demographics. VBC underlying strategy Healthcare Reform, also known 2010.3Salmond S. Echevarria M. transformation changing roles nursing.Orthop 36: 12-25Crossref (107) ACA designed create framework embraces Institute Improvement’s (IHI) Aim patient experience improved population health, reduced expenditures.4Institute ImprovementIHI triple aim initiative.http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspxDate: 2015Date accessed: February 26, 2020Google This fundamental legislation created focus, where providers were rewarded number tests procedures performed structure incentivizes deliver cost.5Aroh D. Colella J. Douglas C. Eddings A. An example translating purchasing into care.J Urol 35: 61-74Crossref call action nursing. Salmond Echevarria3Salmond highlight importance critical player transformation. Nurses are prepared move improve influence outcomes. Medicine6The MedicineThe Future Nursing: Leading Change, Advancing Health. Academies Press, Washington, DC2010Google report Nursing emphasizes significant impact contribution shift, reform. all levels understand vital required committed delivering safe, cost-effective care. active engagement nurses crucial reform, not only affect reimbursement dollars but outcomes across continuum.7Brooks Understanding purchasing.Am 2016; 116: (2) plan transformation, implementation coordination 4 walls an setting drive success. novel approach present challenge most organizations require skill set leaders.8Jacquin L. A strategic transformation.HFM. 2014; 68: 74-79Google understanding principles developing financial acumen, acquiring analytic skills.9Randazzo G. Challenges opportunities facing executives era care.Nurse Leader. 2018; 16: 96-100Abstract Full Text PDF purpose manuscript summary hospitals, highlighting key points leader's transformational leader. article describes current landscape glimpse changes models. Specific implications explored equip leader thrive ACA, value, volume. HVBP, HRRP, HACRP.1Brooks Value, defined CMS, ratio divided cost.3Salmond measured differently each program. HVBP link payment system inpatient through incentive total score (TPS). That TPS calculated domains care, safety, efficiency, experience. Throughout history program, measures weighting domain changed, process outcome efficiency evolved.7Brooks HRRP imposes maximum penalty 3% 30 days all-cause readmissions several cohorts, including myocardial infarction, chronic obstructive pulmonary disease, pneumonia, joints, coronary artery bypass graft surgery. compares actual readmission rate expected years. values then risk-adjusted provide more fair comparison among facilities.1Brooks HACRP 1% those facilities worst-performing quartile. program focuses 5 infections (HAI): catheter-associated urinary tract (CAUTI), central-line–associated bloodstream (CLABSI), surgical site (SSI), Clostridium difficile (CDI), methicillin-resistant Staphylococcus aureus (MRSA) 1 HACRP. second HACRP, composite Agency Research Quality (AHRQ) safety indicators, PSI-90, assessed.2Brooks continued evolve, integration continuum paramount these programs. transformation.5Aroh To ignite changes, staff supports Aim.3Salmond can directly indirectly patent driven results Consumer Assessment Providers Systems (HCAHPS). HCAHPS survey includes questions about topics such discharge planning, communication, responsiveness staff. scores care.10Wolosin R. Ayala Fulton B. satisfaction, purchasing: connections.J Nurs Adm. 2012; 42: 321-325Crossref (41) Another domain, assessment impacted evidence-based interventions basic hand-washing.7Brooks same reduce eliminate well. reducing infections: CLABSI, CAUTI, MRSA, CDI, SSIs. stressed preventing HAIs them 2 separate penalizing twice insufficient areas. Nursing’s role extends pre-discharge post-discharge focus.1Brooks heart coordinated, they seize opportunity, manage arena, transcend boundaries continuum. pivotal many locations continuum.6The skills, episodic patient-centric guides forward.3Salmond Ensuring safe transitions forging collaborative professional partnerships essential latest framework.11Salmond S.W. Forrester D.A. leading change: time now.in: Nursing's Greatest Leaders: History Activism. Springer Publishing Company, New York, NY2016: 270-284Crossref well poised bridge gap fragmented adverse coordination. strategies facilitate family engagement, self-management interdisciplinary collaboration, effective communication.3Salmond first step readmissions, cost. Managing demands model aligns priorities provider services. alignment serves foundation optimizing results. integrated, team-based model, nurses, coordinators transformation.8Jacquin hub links individuals disparate spokes system. They have knowledge, leadership, assume coordination.3Salmond value; however, much broader concentrates patient's needs impacts continuum, trajectory life. Addressing issues entire Individuals conditions, polychronic, Projections show polychronic grow drastically over next 15 years.12Waters H. Graf Cost Chronic Disease U.S. Milken Institute, Santa Monica, CA2018Google Mihailoff et al.13Mihailoff Shreyasi Lee Lynn effects multiple conditions adult finances: management case study.Inquiry. 5446958017729597PubMed demonstrated severe increased lengths stays high rates. Innovations needed navigate uncharted waters rise meet challenges. One concept flipped discharge, elements moved home environment. geriatric identify patients may benefit approach. individualized holistic, comprehensive intensive, timely Other thorough handoff communications in-home assessments functional capacity. Penn Medicine seen promising satisfaction.14Cheney Flip Your Discharge Model Decrease Length Stay. 2018. Health Leaders website.https://www.healthleadersmedia.com/welcome-ad?toURL=/clinical-care/flip-your-discharge-model-decrease-length-stayGoogle addition technology enhancements help complement provider’s reach home. Wearable devices, monitors glucose monitors, transmit portals other sites. innovative tactics remote monitoring drives positive lifestyle changes.15Fields within care.Generations. 2019; Suppl: 24-27Google Hypertension Digital offered Oschner Orleans one establishes connection. Patients given digital device blood pressure readings electronic record. Collaboration team members leads treatment insight gained risk surveys.16Tai-Seale Downing N.L. Jones V.G. Milani R.V. Technology-enabled consumer engagement: Promising practices four organizations.Health Aff (Millwood). 38: 383A-390ACrossref (19) collaboration hallmark pillar transition focal areas legacy practice, which coordination, advocacy, collaboration.17Storfjell J.L. Winslow B.W. Saunders J.S.D. Catalysts Change: Harnessing Power Build Population 21st Century. Robert Wood Johnson Foundation, Princeton, NJ2017Google supported span incorporate norm. increase complexity, further draining resources, approaches, tools revolutionize look future, incorporates expanded conundrum. new, exciting era, chart course big data, change innovation, soaring models.9Randazzo Scholar,18Larson rapidly evolving execs.H&HN. 91: 28-31Google Nurse challenges revolution, futurists who meaningful information great deal data. Big management, provides accomplish Aim. able extract findings analyses convert operational aimed competencies world.19Englebright Caspers chief executive revolution.Nurse 14: 280-284Abstract (4) addition, culture piloting fresh ideas encouraged. status quo no longer accepted. Cultivating internal departmental vital. crosses horizons.18Larson Partnering post-acute establish preferred networks initial process. sit side stakeholders complex cases, settings. Effective cost savings realized if do encompass 360° view. forward, direction clear. specific directions become obscure political agendas mixed reviews effectiveness various evaluated annually Payment Advisory Commission (MedPAC) summarized Congress. payments components annual MedPAC review. Recent reports shown mortality rates slowly, whereas improvement inched along. spending continues sustained prior timeframes.20Medicare CommissionReport Congress: Policy. Commission, DC2019Google Although there growing concern methodology too complicated, repetitive, burden providers. correct flaws, proposed impressive solution, Value Incentive (HVIP). HVIP replace current, seamless hospitals. It elimination Inpatient Reporting (IQRP) merging traditional model. composed all-condition measure, composite, Spend per Beneficiary ratio, perception composite. recommendation implement sent Congress March 2019 awaiting legislative action.20Medicare recognition P4P need streamlined, disparities between social groups Century Cures 2016 FY2019 reflect differences sociodemographic profiles, dual eligibility. Dual eligibility refers fee-for-service coverage qualify Medicaid. Hospitals grouped peer dual-eligible proportion penalty, similar footprint.21Centers ServicesNew Stratified Methodology Hospital-Level Impact File User Guide. Services, Baltimore, MD2017Google decrease penalties high-risk populations. laid factors patient’s status. Social determinants (SDoH) date back 2005 when World Organization SDoH, it until recently SDoH embraced organizations.22World OrganizationSocial Determinants Health.https://www.who.int/social_determinants/strategic-meeting/en/Date: 2019Date 3, housing, food, transportation, employment, education. now included Z-codes ICD 10 coding classification, offer robust method capture record, guide Despite availability codes, very few adopted their use.23American AssociationICD-10-CM Coding Health.https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdfDate: 1, educated assess holistically, context framework, likely profession adopt agenda. realize significance valuable push throughout organization. because sustainable.24Remarks Administrator Seema Verna America's Insurance Plan's (AHIP) National Conference [press release]. MD2019Google Our national state flux, demanding front center complete evidence nursing’s patient-centered, develops demonstrates courage, wisdom, passion navigating unchartered waters. demand full partnership