Nurses: Crucial Collaborators Across the Continuum

1. Nurses: Crucial Collaborators Across the Continuum South Texas Annual Joint Healthcare Conference Healthcare Landscape 2013 San Antonio, Texas January 25, 2013 Presented By: Rhonda Anderson RN, DNSc, FAAN, FACHE Chief Executive Officer Cardon Children’s Medical Center, Mesa, AZ

2. Objectives The participant will be able to: • Explain strategic transition plan to move from illness to health. • Explain role of nurse leader in care coordination. • Explain purposeful workforce transitioning.

3. Important Implementation Dates • Medicare market basket update reductions • Extends dependent coverage for children up to age 26 • High-risk pool established • Patient-Centered Outcomes Research Institute (comparative effectiveness research) • Center for Medicare & Medicaid Innovation • Increased reporting requirements for non-profit hospitals • Accountable Care Organization pilot starts • Hospital Value-Based Purchasing begins • Medicare productivity adjustments • Increased physician quality reporting • Payment adjustments for hospital-acquired conditions • Medicare Commission’s first report to Congress • Reductions in payments for select readmissions • Bundled payment demonstration projects start • Increased Medicaid payments for primary care • Independent Payment Advisory Board established • Medicaid expands to 133% FPL • State Exchanges start • Individual mandate • Employer “play or pay” • Medicare & Medicaid DSH cuts begin • Ban on physician ownership of hospitals • Medicare Advantage payment cuts begin

4. Health Care Reform – Key Themes • Integrative payment models • Accountable care organizations • Bundled payments • Health homes • Quality care / patient safety • Comparative effectiveness • Coordinated care experience • Meaningful use

5. What’s an ACO? An ACO is generally defined as a local health care organization with a network of providers such as primary care physicians, specialists, and hospitals that are accountable for the cost and quality of care delivered to a particular population. Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

6. What’s an ACO? The purpose is to deliver more efficient and coordinated care that is rewarded with a financial bonus for achieving performance benchmarks set by the Centers for Medicare & Medicaid Services (CMS). Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

7. What’s an ACO? The Patient Protection and Affordable Care Act (PPACA) refers to an ACO as a legal entity that includes both physicians and hospitals, has at least 5,000 Medicare lives under contract, has the ability to pay participants, and includes both Medicare and commercial lives. Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 12-13.

8. Four Emerging ACO Models Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

9. 1. Network Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

10. 2. Organized medical group Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

11. 3. Hospital systems Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

12. 4. Collaborative Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine, October 2010, 15.

13. Provider Network (Critical Success Factors) Quality • Top quality (measured by HEDIS/NCQA/Core Measures, 80% OP) • Coordinated patient experience • Standard models of care (evidence-based where applicable) Technology • Technology alignment and adoption (EMR, HIE, Portals, BI Tools) Leadership Culture • High engagement (culture of improvement, learning and accountability) • Physician leadership to drive engagement Coordinated Care • Sharing of data between all parties to improve care and lower cost • Broad geographic distribution and appropriate specialty accessibility and availability • Coordinated Care Low Cost Care • Cost effectiveness (clinical and administrative)

14. Nursing’s Role • Quality Management • Care Coordination • Continuum Management • Role Transitions

15. Aligning Payment with Quality: Accountable Care Organizations • MEDICAID • Beginning January 1, 2012, establishes a 5-year ACO demonstration project for pediatric providers to share in cost savings achieved for Medicaid and CHIP. • Providers would have to participate in pilot for a minimum of 3 years. • MEDICARE • By January 1, 2012, requires DHHS to create a program that would reward hospitals and physicians (ACOs) that work together to manage patient costs and quality of care to Medicare beneficiaries. • ACOs can include physicians, hospitals, nurse practitioners, physician assistants and others. • ACOs would be rewarded for meeting quality of care targets and cost reductions. • Preference may be given to ACOs already contracting with the private market. PPACA: Sec. 2706, 3022, 10307

16. Aligning Payment with Quality: Health Homes MEDICAID • Beginning January 1, 2011, creates a Medicaid state plan option that allows a provider or group of providers to be designated as a medical home for enrollees with at least two chronic conditions. • The health home must have systems and infrastructure in place to provide: • Comprehensive care management • Care coordination and health promotion • Comprehensive transitional care • Patient and family support • Referral to community and social services • The health home may be a free-standing, virtual or hospital-based, community health center, community mental health center, clinic, physician’s office or physician group practice. • Provides a 90% federal match to state for 2 years. MEDICARE • Beginning January 1, 2012, creates a Medicare pilot targeting physician and nurse practitioner-directed home based primary care teams. • Teams are responsible for providing comprehensive, coordinated, and continuous care to at least 200 high-need beneficiaries at home. • May share savings in excess of 5 percent. PPACA: Sec. 2703, 3024

17. ALIGNING PAYMENT WITH QUALITY:PAY FOR PERFORMANCE • Beginning October 1, 2012, establishes a Medicare value-based purchasing program for hospitals that ties a percent of payments to performance on quality measures starting with: Acute Myocardial Infarction, Heart failure, Pneumonia care, surgery infection prevention, healthcare-associated infections and patient satisfaction. • In 2014, will include efficiency measures & Medicare spending per beneficiary • Hospitals rewarded for attainment and improvement on performance. • Incentive funding comes from reductions that apply to all MS-DRGs: • Individual hospital performance on each measure will be publicly reported. • Starting March 23, 2012, 3-year demonstration project to test for CAHs, small hospitals, IRFs, psychiatric hospitals, cancer hospitals and hospice. • Establishes value-based purchasing program for ASCs. PPACA: Sec. 3001, 10335

18. ALIGNING PAYMENT WITH QUALITY:HOSPITAL READMISSIONS • In June 2008, MedPAC recommended that Congress reduce payments to hospitals with relatively high readmission rates for select conditions. • Beginning October 1, 2012, CMS will adjust inpatient payments for “higher-than-expected” Medicare readmission rates based on 30-day readmissions for: • Heart Attack • Heart Failure • Pneumonia • In 2015, expands to COPD, CABG, PTCA and other vascular • Reduction is applied to all DRGs. • Reductions cannot exceed: • DHHS may expand the policy to include additional conditions. • Readmission rates for certain conditions will be made available to the public. • CAHs are exempt. PPACA: Sec. 3025

19. ALIGNING PAYMENT WITH QUALITY:PAYMENT BUNDLING • MEDICAID • Beginning on January 1, 2012, establishes a bundled payment pilot program under Medicaid in up to 8 states. • Focus on episode of care that includes hospitalization and concurrent physician services. • MEDICARE • Beginning January 1, 2013, establishes a 5-year national, voluntary pilot program for hospitals, physicians and post-acute care providers to improve coordination, quality and efficiency through bundled payment models. • Pilot program will cover inpatient, outpatient, post-acute care (IRFs, SNFs, HHAs & LTCHs), & physician services. In June 2008, MedPAC made recommendations designed to improve the efficiency of hospital episodes, such as bundled payments for select services. PPACA: Sec. 2704, 3023, 10308

20. Patient-Family Engagement ●Care Coordination ●Case Rates ●Utilization ●Readmissions Post-Acute Bundles F1.1 F1.2 Avatar Meaningful Use ACO Population Health Ambulatory Strategy L3 Value-Based Purchasing Quality Safety HAI Ambulatory Strategy Physician Strategy

21. Fifteen Imperatives for success under accountable care Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

22. Physician alignment • Focus physician alignment structures on premium partners who share a common vision of success: value creation, not the immediate upside of a transactional liquidity moment. • Organize accountable care networks around proceduralists who will comprise the efficient surgical enterprise, and primary care physicians and medical specialists who will operate the effective ambulatory care management network. • Develop physician alignment strategies that support joint contracting with all physicians who will be “principals” of your accountable care enterprise. Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

23. Clinical transformation • Engage stakeholders from multiple levels and sites of care to engineer a dramatically more efficient accountable care enterprise. • Begin clinical transformation initiatives within the acute care enterprise to generate returns to address performance risk and fund investments in managing utilization risk. • Activate patients under your care by engaging patients in decision-making both during acute events and before acute events occur. • Develop an advanced primary care medical home model that supports proactive chronic care and longitudinal patient management. Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

24. Payment transformation • Synchronize clinical transformations that reduce demand with changes in fee-for-service payments to capture value created and to avoid accepting too much risk too soon. • Pilot population management strategies with the hospital’s own self-insured employee base to perfect the clinical model and capture early value created. • Implement new payment innovations from the “inside out,” focusing on changes that maximize the profitability of existing businesses to fund investment in longer-term changes in capabilities and incentives. • Design a roadmap for payer contracting strategy based on value creation for purchasers rather than the exercise of leverage. Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

25. Information-powered health care • Maximize physician engagement in performance improvement with investments in technologies that identify improvement opportunities connected to contractual incentives. • Re-orient clinical operations around process design and care standardization in order to unlock the full value of greater IT investment. • Inform clinical model redesign, population risk assessment, and targeted patient management through sophisticated data analytics and business intelligence. • Support population management through investments in technologies that provide remote and virtual access to medical advice and monitoring. Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.

26. What is YOUR piece of the puzzle? Acute Care ?

27. Workforce Transformation • Current acute care mentality • Transition planning • Redistribution of clinicians

29. ~Questions~Thank you