HEALTH EXPENDITURES in

Perspectives in Ambulatory Care Yumi Ma Nancy May Courtney Knotts Annette DeVito Dabbs Opportunities for Nurses to Lead Quality Efforts Under MACRA EXECUTIVE SUMMARY Care planning and care coordination are quality metrics for Medicare Access and CHIP Reauthorization Act (MACRA). Registered nurses in ambulatory care were surveyed to assess current care coordination practices and identify opportunities for RNs to promote quality under the law. Findings can assist in understanding the ways nurses in ambulatory care currently contribute to quality outcomes and identify additional opportunities for registered nurses to lead efforts to continue to improve quality under MACRA. HEALTH EXPENDITURES in the United States exceed those of other highincome countries, yet health disparities persist (Squires & Anderson, 2015). The demand for health care is burgeoning, yet healthcare needs are often unmet or escape attention (Dzau et al., 2017). The consequences can be devastating, particularly for highrisk populations who experience Yumi Ma greater instability, severity, chronicity, and multiple comorbid health conditions (Hayes et al., 2016). Persons with complex physical, behavioral, and social needs are the most likely to fall through the cracks because health care that is fragmented and compartmentalized raises the risk for lapses in care, especially during periods of transition (Coleman, 2003). As the complexity of care increases, so does the number of providers involved in a person s care across multiple settings. Without coordination of care YUMI MA, MSN, RN, is Doctoral Student, University of Pittsburgh School of Nursing, Pittsburgh, PA. NANCY MAY, DNP, RN-BC, NEA-BC, is Chief Nursing Officer, University of Michigan Medical Group, Ambulatory Care, Ann Arbor, MI. COURTNEY KNOTTS, is Bachelor of Science in Nursing Student, University of Pittsburgh School of Nursing, Pittsburgh, PA. ANNETTE DEVITO DABBS, PhD, RN, ACNS-BC, is Professor and Chair, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA. delivery, services may be poorly aligned with a person s wishes, redundant, unnecessary, ineffective, or potentially harmful. Subsequent health outcomes may be less than ideal while costs escalate. A central aim of healthcare reform is to improve the quality of care coordination to manage the complex health needs of the population, improve quality, and manage healthcare costs. Improving the quality of care coordination is one of the main strategies to achieve the Triple Aim of better care for individuals, populations, and lower per capita healthcare costs (Berwick, Nolan, & Whittington, 2008). Care planning and care coordination are foundational to achieving the healthcare reform goal of improving quality of care (Anderson et al., 2015). The Medicare Access and CHIP Reauthorization Act (MACRA), thought to be one of the biggest changes in Part B Medicare reimbursement in the history of Medicare, was signed into law in 2015 and become effective April 2016 (Speed & Drevna, 2016). Reimbursement under MACRA shifts from fee for service to pay for performance to incentivize care transformation efforts for practices to increase quality and decrease costs. A number of provisions in the law directly relate to care planning and care coordination. The quality indicators for reimbursement under MACRA align directly with transformations in healthcare delivery. Registered nurses (RNs) possess the knowledge and skills to lead teambased care coordination efforts to increase quality and decrease cost under the law (Swan & Haas, 2011). Medicare Access and CHIP Reauthorization Act MACRA replaced the Sustainable Growth Rate formula developed to control costs; however, little impact was placed on the quality of care or patient acuity. Two new tracts, Merit Based Incentive Plans (MIPS) and Alternative Payment Models (APMs), were developed to move toward value-based care and away from fee for service. Under MIPS, bonus payments will be obtained by reviewing the previous 2 years with data measurement starting January 2017 and with a bonus payout in 2019 using 2017 data sets. With MIPS, requirements include reporting on 6 of NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing (AAACN) and edited by Kitty Shulman, MSN, RN-BC. For more information about the organization, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ 08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 589-7463; Email: aaacn@ajj.com; Website: http://aaacn.org 97

Table 1. Team Members Eligible to Assume the Role of Care Manager (n=424) Team Members n % RN with experience and/or special training in care coordination 328 77.36 Social worker with experience and/or special training in care coordination 96 22.64 RN with master s or other graduate degree 77 18.16 Social worker with master s or other graduate degree 57 13.44 Member of another licensed discipline with experience and/or special training in care coordination 55 12.97 Care coordinator/care manager certified by an organization other than MSNCB (e.g., ANCC, CCMC) 55 12.97 Care coordinator certified by MSNCB 42 9.91 Member of another licensed discipline with master s or graduate degree 25 5.90 Contracted care manager 13 3.07 Other (please specify) 79 18.63 over 300 quality measures; however, one measure must have an outcome associated with it across multiple settings (Speed & Drevna, 2016). MIPS payment models are based on criteria met with weighted specifications in each category: Quality 50%, Advance Care Information 25%, Resource Use 15%, and Clinical Improvement 10%. MACRA provides another payment model for which there are stringent metrics in addition to MIPS measures. This model is in a category of APMs. Under APM, bonus payment is allocated at the beginning of each year with higher financial risk if metrics are not met resulting in less payment. If successful in achieving the metrics, a higher bonus payment in the form of dollars is paid to reinvest in the practice. The bonus structure is based on the number of beneficiaries, quality metrics, and risk associated with the population and use of electronic health records (EHRs) for care delivery. The Centers for Medicare & Medicaid Services anticipate the additional bundled services will improve access to care and force movement towards capitation, lowering overall cost and improved quality (Panjamapirom & Lazerow, 2017). The APM increased the urgency to develop care teams to meet the challenges of prioritizing quality performance metrics and cost control along with developing seamless care coordination. With changes under MACRA and leveraging the role of the RN, members of the American Academy of Ambulatory Care Nursing (AAACN) were invited to complete an electronic survey to assess the state of care coordination and care planning in ambulatory care settings, including the use of electronic care planning (ECP). The survey was sent to 4,146 members, of which 424 (11%) responded. As a result of identifying gaps that existed at the time of the survey, AAACN survey results will help position members to lead nursing care coordination efforts. There were two study limitations: many questions allowed the selection of multiple responses, and response rate was moderate. Findings Care management. The composition of providers and services co-located within the ambulatory care practices were mostly RNs (n=409, 96.5%), physicians (n=402, 94.8%), advanced practice providers (n=377, 88.9%), unlicensed personnel (n=305, 71.9%), social workers (n=249, 58.7%), and embedded care managers (n=151, 35.6%). However, only 4.3% (n=18) of contracted care managers were colocated within the ambulatory care practice community. In addition, pharmacists (n=258, 60.8%), behavioral health professionals (n=247, 58.3%), physical therapists (n=242, 57.1%), occupational therapists, social workers, durable medical equipment vendors, and community services (e.g., housing, meals, transportation) were less likely to be considered members of the practices, particularly when they were not colocated. When respondents were asked to name team members eligible to serve as care managers in their practice setting, the majority identified RNs and/or social workers (see Table 1). Most care managers were co-located within the ambulatory care practice settings. Care planning. Approximately half of respondents reported using care plans in their practices 98

Table 2. Elements Captured in the Care Plan (n=151) Elements n % Action plans for specific conditions 120 79.47 Interventions 110 72.85 Advanced directives 85 56.29 Health status evaluations and outcomes 84 55.63 Preferences for care 69 45.70 Identified care gaps 66 43.71 We do not use care plans 5 3.31 Other (please specify) 24 15.89 Table 3. Team Members Permitted to Make Changes to the Care Plan (n=148) Team Members n % Any member of the care team who is co-located in the practice 84 56.76 Any member of the extended care team 32 21.62 Only a care manager 28 18.92 Our care plans are not interactive 21 14.19 The patient and/or family/surrogate 4 27.0 Other (please specify) 23 15.54 (54.6%), with ECPs used more often than either paper or a combination of electronic and paper versions. The most common elements captured in the care plans were action plans and interventions for specific conditions (see Table 2). The majority of care plans were integrated into the EHR. Respondents preferred individualized ECP over use of standard care plan modules provided by their vendors. Approximately 14.2% of practices used care plans that were not interactive. Of the 148 respondents who reported using ECPs, over half (n=84, 56.8%) granted every member of the practice community access to the care plan regardless of location, with the exception of community service providers who were rarely granted access. Typically only providers who were co-located were permitted to make changes to the care plan. (see Table 3). For the majority of practices that used ECP, a practice-based care manager or care coordinator was responsible for oversight of ECP. Very few practices contracted with care management companies for care planning. Nearly two-thirds of respondents reported use of ECPs increased their workload (see Table 4). Of practices that used ECPs, copies were made available to the patient as a paper printout or through websites, portals, or both. While patients preferences and goals were included in care plans, they were rarely involved in modifying or updating the care plans directly. Discussion and Implications To our knowledge, this is the first assessment to characterize current roles of RNs in ambulatory care settings and their current utilization of care plans, particularly ECP formats. While RNs reportedly served as care managers in the vast majority of practice settings, in some cases social workers and other team members were also considered eligible. In general, practices that delegate the care manager role to non-nurses in an attempt to reduce costs lack an appreciation of the value proposition of RNs for 99

Table 4. Impact of Electronic Care Planning on Clinician Workload (n=139) Workload n % Moderately increases 72 51.80 No effect 28 20.14 Significantly increases 21 15.11 Moderately reduces 15 10.79 Significantly reduces 3 2.16 achieving cost-effective and quality health outcomes for complex patients (AAACN, 2017). Results of this survey confirm care managers play a significant role in care coordination and care planning. However, care plans are currently used by only half of respondents. Usually, the care manager is responsible for assessing patients preferences and goals and incorporating them in the care plan. While care plans are discussed, modified, and shared with members of the care team, patients and families rarely have the opportunity to modify or update their care plans directly. Therefore, care managers should include patients and families in the care planning process to ensure their needs are met and care is patient centered. While survey findings are encouraging, there is still the need to determine which models best support patient-centered, team-based care planning and coordination including the variety of possible roles, responsibilities, and competencies of various members of interprofessional teams. Coordination of care has often been less than ideal because tools supporting communication and comprehensive shared care planning between providers and across settings are scarce. Health information technology tools are now available to support the level of information exchange and communication required for care planning and care coordination among multiple providers across settings and time. Practices that used ECPs relied on vendor products embedded in the EHR. However, the majority of respondents reported that use of ECPs increased their workload. This finding is consistent with reports of the potential provider burden associated with use of EHRs and other digital documentation, which led to the recommendation the Triple Aim be expanded to include a quadruple aim: to improve the work life of healthcare providers (Bodenheimer & Sinsky, 2014). It also points to the need to improve the care planning process to reduce the burden on RNs in order to position themselves as gatekeepers managing ECP across the continuum. Other major barriers to care coordination have been lack of effective orchestration, communication, and engagement of all members of the care team (including individuals and their family members) between providers and across settings (Mitchell et al., 2012; Press, 2014). There are several ways RNs are instrumental in helping ambulatory care practices coordinate and improve care delivery to meet the reimbursement criteria for MACRA. For instance, RNs impact care coordination by setting up 24/7 access to care through call centers, developing patient care advisory boards, and engaging patients in their care with goal setting. RNs effectively manage panels of patients to improve access to care. They establish alternative ways to deliver care thereby increasing engagement of patients and access to care beyond conventional settings. Leveraging digital platforms of telehealth and remote monitoring reduces cost and monitors changes in patients conditions to detect problems and intervene in a timely manner. RNs partner with local pharmacies, grocery stores, and urgent care centers to maximize contributions and integrate efforts of other community and service providers. Nurses expand their impact to meet quality metrics for reimbursement by integrating strategies targeted to improving actionable social and behavioral determinants of health, including behavioral and mental health. Ambulatory care nurses should focus on persons with complex needs and the rising risk population to have the greatest impact on health promotion and prevention (Smolowitz et al., 2015). The need to respond to this crisis by professional nurse organizations and nursing communities is long overdue. To this end and to improve care for patients with chronic disease needing effective care coordination between care settings, AAACN developed a course in Care Coordination and Transition Management (CCTM ), collaborated with the Medical-Surgical Nursing Certification Board to develop a CCTM certification, and published the Care Coordination and Transition Management Core Curriculum (Haas, Swan, & Haynes, 2014). Nurses are well positioned to lead efforts to man- 100

age the care needs of patient populations utilizing a care plan across settings. RNs coordinate efforts of interprofessional and community providers to be actively engaged to meet population care needs. In fact, the value of professional nurses fulfilling these roles in ambulatory care settings is well documented (AAACN, 2017). AAACN s strategic plan is focused on the role of the RN in care coordination, telehealth nursing, and developing nurse-sensitive indicators in ambulatory care practice. The reimbursement models that reward such activities are followed closely to identify ways for RNs to meet the needs of patients with complex care needs, build on our longstanding roles in care planning and care coordination, and seize new opportunities (AAACN, 2017). Findings of this survey assist in understanding ways nurses in ambulatory care currently contribute to quality outcomes and identify additional opportunities for RNs to lead efforts to continue to improve quality under MACRA. $ REFERENCES American Academy of Ambulatory Care Nursing (AAACN). (2017). American Academy of Ambulatory Care Nursing position paper: The role of the registered nurse in ambulatory care. Nursing Economics$, 35(1), 39-47. Anderson, G.F., Ballreich, J., Bleich, S., Boyd, C., DuGoff, E., Leff, B., Wolff, J. (2015). Attributes common to programs that successfully treat high-need, high-cost individuals. American Journal of Managed Care, 21(11), e597-e600. Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs (Millwood), 27(3), 759-769. Bondenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals Family Medicine, 12(6), 573-576. Coleman, E.A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555. Dzau, V.J., McClellan, M.B., McGinnis, J.M., Burke, S.P., Coye, M.J., Diaz, A., Zerhouni, E. (2017). Vital directions for health and health care. JAMA, 317(14), 1461. Haas, S.A., Swan, B.A., & Haynes, T.S. (Eds.). (2014). Care coordination and transition management core curriculum. Pitman, NJ: American Academy of Ambulatory Care Nursing. Hayes, S.L., Salzberg, C.A., McCarthy, D., Radley, D.C., Abrams, M.K., Shah, T., & Anderson, G.F. (2016). High-need, high-cost patients: Who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. Issue Brief (Commonwealth Fund), 26, 1-14. Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Von Kohorn, I. (2012). Core principles and values of effective team-based health care. Retrieved from https:// www.nationalahec.org/pdfs/vsrt-team-based-care-principlesvalues.pdf Panjamapirom, T., & Lazerow, R. (2017). 10 Takeaways on the 2018 MACRA Final Rule. Retrieved from https:// www.advisory. com/ research/ health-care-advisory-board/blogs/ at-thehelm/2017/11/ 2018-macra-final-rule Press, M.J. (2014). Instant replay A quarterback s view of care coordination. New England Journal of Medicine, 371(6), 489-491. https://doi.org/10.1056/nejmp1406033 Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E.M., Ulrich, S., Hayes, C., & Wood, L. (2015). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130-136. Speed, C., & Drevna, D.M. (2016, June). MACRA: Are you ready for risk? Time to prepare far-reaching changes in physician payment. Group Practice Journal, 7-13. Squires, D., & Anderson, C. (2015). U.S. h ealth care from a global perspective: Spending, use of services, prices, and health in 13 countries. Retrieved from http://www.commonwealthfund.org/ publications/issue-briefs/2015/oct/us-health-care-from-a-globalperspective Swan, B.A., & Haas, S.A. (2011). Health care reform: Current updates and future initiatives for ambulatory care nursing. Nursing Economic$, 29(6), 331-334. 101