1. Hader, Richard PhD, NE-BC, RN, CHE, CPHQ, FAAN

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Each time we think we've adjusted to the newest model of healthcare reimbursement, there's another one around the corner. Considering that billions of dollars per year fund healthcare delivery, dramatic changes in the system must occur or we'll individually and globally suffer a dramatic financial collapse.

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Many nurse leaders believe they're insulated from economic breakdown because "someone" will find a better way to deliver care. However, whether that someone is the government, commercial payers, or lawmakers, the result is the same-less available money. It falls directly on us, nurse leaders closest to the bedside, to implement very different models of care to handle the new payment structures.


Healthcare leaders throughout the country are preparing a plan for economic survival, as insurers migrate from a "fee-for-service" payment to a bundled payment plan. This new schedule is based on insurers paying one fee for care throughout the continuum. There are several major changes to this plan, most important, the creation of an Accountable Care Organization (ACO)-a partnership between physicians, insurers, and the provider organization (for example, hospitals and rehabilitation facilities).


This new payment method hinges on an economic partnership between physicians and clinical organizations. Hospital executives are feverishly recruiting physicians to join their ACOs to secure business. Voluntary physicians, those in their own business, are being approached to join an ACO, which offers financial benefits for the physician, hospital, and, ultimately, the patient. The key to this strategy is to build a clinically integrated network that monitors quality initiatives rooted in evidence-based care and protocols.


Although many of these plans and financial arrangements emerge without input from nurse leaders, the effects of these changes will significantly impact the manner in which care is delivered throughout the continuum. Nurses, physicians, and other healthcare providers will need to make drastic changes in their care delivery system to ensure the new payment system's success.


Interdisciplinary boundaries will be broken, as complete collaboration surfaces among disciplines and concurrently across the care continuum. New, transparent pathways of care will emerge among providers and patients to ensure continuity, safety, and lower costs, all while improving the quality-of-care delivery.


Implications for nurse leaders

This latest redesign of the healthcare infrastructure spurs several dominant and necessary changes. Let's take a look at the most-affected areas.


The role of nurse managers

The traditional unit-based nurse manager is likely to change, as the care delivery model evolves from a short-term episodic experience to awareness and management of care transitions that incorporate prevention, acute intervention, rehabilitation, and chronic and long-term care. Nurse managers will need to educate themselves regarding the needs of the patient post-discharge from the acute care setting. In collaboration with the healthcare delivery team, the nurse manager must orchestrate and facilitate models of care that allow for appropriate planning and follow-up between clinical settings.


Clinical rounds to plan for discharge from the acute care setting need to be strengthened. To allow for time to effectively plan, nurse managers and their teams must communicate about what activities need to be provided by RNs and those that can be delegated to other members of the team. Often, when nurses begin to describe many of their duties and responsibilities, they discover that these activities can be conducted by others-or not done at all. Developing structures and processes that other members of the staff can easily follow will allow the nurse manager to be more productive by planning, coordinating, and improving the care delivered to patients.


Although it's often uncomfortable for nurse managers to think and plan outside the walls of their clinical expertise, doing so will improve quality metrics, and patient and staff satisfaction. It'll also decrease overall costs. This new skill must be learned through self-motivation and creating a template for the new model of care delivery.


Financial accountability of disease management is a new competency for nurse leaders to master. Traditionally, nurse managers needed to be competent in managing salary and supply expense. In the new payment methodology, nurse managers will be held accountable for unnecessary costs related to the patient's overall stay. For example, if a patient develops a pressure ulcer while being cared for in the hospital, payers won't reimburse the hospital for the care needed to treat the wound. Nurse leaders will be accountable for these costs if it's determined that appropriate preventive mechanisms weren't in place to prevent the ulcer.


Rapid deployment of APRNs

Advanced practice registered nurses (APRNs) will soon be a rare commodity, as physician practices and healthcare organizations compete to hire these professionals. Physicians and hospital administrators recognize the value of APRNs in the delivery of high-quality, low-cost healthcare. Due to their clinical expertise, APRNs have demonstrated the ability to plan and implement healthcare for a large variety of patient populations.


As the aging patient demographic increases, APRNs will become invaluable in caring for patients with chronic illness. Diseases, such as chronic obstructive pulmonary disease, diabetes, and congestive heart failure, as well as end-of-life care, can be easily treated efficiently and effectively by APRNs to relieve primary and specialty care physicians from routine monitoring and exam.


All practitioners need to rise to their "top of license," which means working up to their level of education and training. State boards of nursing and state lawmakers must immediately cease limitations on APRN practice to better meet the community's healthcare needs.


Nurse managers must connect with APRNs, inviting continuum-based APRNs into individual units and departments to educate nurses on the practices delivered in acute care.


Comprehensive integration of evidence-based care protocols and guidelines

What was once called "cook book medicine" is now considered best practice. The use of guidelines and scientifically proven protocols has gained acceptance by nurses and physicians. Standardizing protocols based on evidence supported by the use of computer technology has further aided the implementation of care standards.


All organizations that receive governmental reimbursement are required to report clinical process measures and outcomes to ensure that care is delivered within nationally approved standards. Most of these measures monitor nursing or medical care. Standards must be accurately completed in a timely fashion based on the use of scientific protocols. These reports, which are published as required by legislation, compare performance of institutions.


Nurse leaders need to consistently work with their staff members to ensure that care is delivered appropriately 100% of the time. Any defect is noted and readily available to the public, and commercial and government payers. Failure to meet these measures results in decreased reimbursement from payers.


Value-based purchasing, a reimbursement program implemented by the federal government, has been designed to engage hospitals to achieve clinical excellence and improve patient satisfaction. Clinical indicators, such as care of the patient with an acute myocardial infarction or congestive heart failure, and surgical indicators are compared with other hospitals. If your hospital doesn't meet the standard of performance, it could lose millions of dollars in revenue. Throughout the next several years, this new payment methodology may significantly impact the bottom line of healthcare organizations.


Improved transitions of care

In most cases, care is delivered in an episodic manner. Although discharge planning and follow-up have long been required, there aren't mechanisms to follow the care of the patient through the transitions of care. There are major gaps between healthcare organizations and physician practices because there's little or no infrastructure provided that allows for plans of care to be transitioned between providers. We need to build new communication platforms to better manage care across the continuum.


Our current system is difficult for patients to navigate. Those seeking healthcare are often confused with what steps they need to take. Often, patients are treated by numerous specialists and the care plan isn't clear. Patients need to be assigned a professional nurse to help navigate the disease process. Long-term follow-up care is necessary because many illnesses are treated as chronic diseases.


Nurse navigators are relatively new to our profession. These individuals work with the patient to ensure that provided care is well coordinated. The navigator follows the patient and provides a support mechanism for patients and families to help them receive appropriate care. The foundation of this delivery system is developing and utilizing digital systems that can readily retrieve and analyze clinical data and outcomes.


Although many organizations are working to develop better electronic communication systems between providers, few have been able to communicate effectively between various levels of care. Despite monetary incentives for physician practices to implement electronic documentation systems that can be retrieved, countless barriers have prevented total acceptance of this technology.


Vendors compete with each other to provide efficient electronic documentation systems to healthcare practices. Frequently, the vendors, themselves, are still developing these software packages, which may impede physicians and organizations from making a purchase. Also, installation can get costly and time-consuming, which doesn't help matters in an economic era where private practitioners are caring for a high volume of patients.


Advanced nursing education

Nurse leaders need to advance their education to meet expanding responsibilities. Graduate-level work in the areas of finance, organizational planning, and effectiveness are necessary to identify and resolve the issues related to societal health. Nurse leaders need to develop skills that will allow them to execute a vision for the methods to integrate healthcare throughout the continuum.


As previously mentioned, APRNs will be in great demand. The American Association of Colleges of Nursing is preparing to advance the requirement for APRNs to earn a Doctor of Nursing Practice (DNP) degree. Many DNP programs offer students the opportunity to explore new care delivery systems. The DNP graduate will be able to translate research into practice to accelerate meeting the community's healthcare needs. Highly skilled and educated DNP graduates have the ability to collaboratively work with all healthcare disciplines to provide the implementation of new knowledge and innovation to improve overall health.


Nurse leaders need to advocate for the financial resources necessary for nurses to continue their education. Funding for advanced graduate work needs to be part of your organization's infrastructure. Nurses continuing their education should be able to benefit from financial incentives, just as medical students and residents receive.


The use of data

Data that don't produce information are worthless. There's a significant amount of data that nurse leaders are required to collect, but very little of them yield valuable information. Data need to be appropriately collected and scientifically analyzed to ensure their appropriate use. The level of data analysis will determine the meaningfulness of the information.


Nurse leaders need to learn to appropriately analyze data to determine the effectiveness of care provided. Tracking and trending data can be beneficial determine the appropriate course of treatment and its effectiveness based on quality information.


Data transformed into meaningful information can help develop strategies, improve care, manage risk, maximize economics, and lead to better clinical outcomes. Nurse leaders who can effectively garnish data and analyze them appropriately will be more effective in making decisions that enable improved outcomes.


Moving forward

A myopic view of delivering episodic care is over. To be successful healthcare leaders, nurses need to be visible and collaborative in both the boardroom and the clinical setting. More than ever, nurse leaders must require nurses at all levels of the organization to be cognizant of the quality of patient care delivered at the lowest possible cost. Better care outcomes are everyone's responsibility, but the nurse leader is the point-person for advancing the cause.