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With healthcare costs spiraling higher, the federal government aims to create more efficient care delivery while improving quality through Accountable Care Organizations.
"This is taking [healthcare] to another level," said Walter Le-Strange, RN, MPH, ACMPE, the COO at ProHealth Accountable Care Medical Group of Lake Success, N.Y., one of 88 ACOs that joined the Centers for Medicare & Medicaid Services Medicare Shared Savings Program in July. The government estimates the shared-savings program, made possible by the 2010 Affordable Care Act, could save as much as $940 million during the next four years.
"We need to improve quality and reduce unnecessary expense in healthcare," said Anthony Slonim, MD, DrPH, executive vice president and chief medical officer of Barnabas Health ACO-North in West Orange, N.J., which serves 8,700 patients. "The ACO approach is to align all of the multiple constituents that provide that care."
About 400 physicians, Barnabas and other entities will work together to help patients live healthier lives and obtain recommended screenings and other preventive services while dealing with transportation and other social factors that affect outcomes, such as medication costs.
"The healthcare system is not well-designed to deliver that sort of care," Slonim said. However, if the ACO comes up with innovative solutions and succeeds in addressing these patient issues, it likely will save money to be shared with CMS. Barnabas will give 90% of its portion of the savings to participating physicians.
"We’re not expecting huge savings," Slonim said. "It’s an opportunity to learn how to do this kind of care."
A focus on quality
Saving money represents only part of CMS’s goal. ACOs must report on 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experiences.
"In order to succeed, we have to not only reduce expenses but improve the quality of care," said Carole Romano, director of regulatory affairs, patient outreach and patient education at ProHealth. The 350-physician practice serves 21,000 Medicare beneficiaries in the New York tri-state area.
"The benefit of shared savings is the potential for revenue to invest in our infrastructure and develop new services," Romano said. That may pay for staff, equipment, new urgent care centers and other resources as well as to reward "primary care doctors for going above and beyond the usual scope of their practice to take a more comprehensive approach to their patients."
Information will help ACOs target patients most in need of intervention. WestMed Medical Group ACO in Purchase, N.Y., serving 13,000 Westchester County patients, focuses on people with chronic diseases. The 250-physician multispecialty practice has documented electronically since 2002, and clinicians can pull data and keep track of preventive needs. "We are not only managing patients who come in on a regular basis but also population management of patients who have dropped off our radar," said Janet Rella, RN, MSN, the CNO at WestMed. Those patients receive a call to come back to see a provider.
CMS will provide the ACOs beneficiary expenditure data for every visit, and hospitalization for the past three years. LeStrange said that allows an ACO to identify patients with frequent ED visits or other high utilization. Then, the ACO can target those people for better management.
Although the ACO will focus on the 5% at greatest risk, LeStrange said ProHealth will not ignore the other 95%, but rather ensure they receive recommended preventive services. "We are not going to be passive," he said. "We are going to do outreach."
Growth opportunities for RNs
Slonim envisions new roles for nurses in outpatient settings, managing population-based care and coordinating with other providers.
"There are innovative ways for nurses to put their heads together about what this arena might present as far as opportunities," Slonim said.
At WestMed, RN case managers meet in person with "outliers," patients requiring additional services, and develop a plan of care based on patient goals. Case managers also work with patients’ "champions," people who will help them achieve those goals.
"We’re trying to engage the patients," said Maureen Adams, RN, MBA, associate director of clinical operations at WestMed.
Nursing also provides the foundation for WestMed’s palliative care program, in which an advanced practice nurse helps patients think through treatments and complete advance directives, with a goal of keeping him or her comfortable at home. "It’s an exciting time for nurses," Adams said, calling ACOs a growth opportunity.
ProHealth RN care coordinators will contact at-risk patients, identify barriers to care and figure out solutions, perhaps recommending a home-health nurse visit the patient or arranging for other community services. "It’s a relatively new career path for nurses — care coordination in the physician practice," LeStrange said.
He called it an ideal role for nurses because they are uniquely qualified for coordinating at this level.
"It’s a wonderful improvement in quality of care, and nurse care coordinators will be champions in this role," he said.