Brenda Recchia Jeffers PhD RN is Chancellor and Dean St. Johns College Springfield IL; and Kim S. Astroth PhD RN is Assistant Professor Mennonite College of Nursing Illinois State University Normal IL.
Keywords
Clinical nurse leader healthcare
reform integrated care delivery
nursing education
Correspondence
Brenda Recchia Jeffers PhD RN
Department of Nursing St. Johns
College Springfield IL
E-mail: Brenda.jeffers@
stjohnscollegespringfield.edu
Jeffers Astroth
PROBLEM. Passage of the 2010 Patient Protection and Affordable Care
Act will require change in the healthcare systems. The clinical nurse
leader must be prepared to lead and shape the changing environment to
achieve maximum outcomes for patients and families. Movement toward
integrated care delivery across the care continuum the transition of the
Centers for Medicare & Medicaid Services to a value-based funding
model and accountability for high-quality cost-effective care are just
some of the drivers of this new integrated healthcare system.
IMPLICATIONS. Reimbursement models that reward those health
systems that are able to meet benchmark performance standards will
result in major shifts in how health systems operate. Expertise in care
coordination across the healthcare continuum is essential for maximum
reimbursement. Payment for value instead of volume delivered is a major
reimbursement transition coming to the acute care setting necessitating
increased attention to mining data necessary to capture quality patient
outcomes for maximum reimbursement.
CONCLUSIONS. The clinical nurse leader is ideally suited to function
within these integrated systems of the future and possesses the skills
needed to assist healthcare systems to meet this challenge.
The healthcare system as we know it is changing
rapidly. With these changes the nurse must be prepared
to shape and lead the emerging environment to
achieve the highest outcomes for patients and families.
Some of the drivers of this emerging system are as
follows: (a) movement toward integrated care delivery
across the care continuum (b) the Centers for Medicare
& Medicaid Services (CMS) transition to a new
value-based funding model and (c) accountability
for high-quality cost-effective care. Reimbursement
models that reward health systems meeting benchmark
performance standards will result in major shifts
on how health systems operate. The clinical nurse
leader (CNL) a new nursing role introduced by the
American Association of Colleges of Nursing (AACN)
in 2003 is ideally suited to assist healthcare environments
to meet this challenge. The CNL is a mastersprepared
nurse generalist educated with competencies
needed in this new time to assure quality healthcare
delivery. The CNL focuses on safety quality outcomes
evidence-based practice care coordination advocacy
and financial stewardship (AACN 2007). This focus
makes this care provider uniquely prepared to lead
change and high performance across the health
system.
The Institute of Medicine (IOM) report The Future
of Nursing (2010) challenges the nursing profession as
well as the entire healthcare system to examine the
implications of their recommendation that all nurses
work to the maximum extent of their education
and leadership competencies. Examination of the
masters-prepared nurse generalist educated within
the CNL curricular framework provides an opportunity
to reflect on the graduate competencies optimal
function and leadership opportunities for this nursing
role. While the CNL role was designed prior to The
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Future of Nursing report and the passage of the 2010
Patient Protection and Affordable Care Act IOM
reports such as the Health Professions Education: A
Bridge to Quality (2003) influenced the development of
the CNL role (AACN 2007). The recent IOM round
table on the learning health system (IOM 2011)
articulates that the use of high-quality evidence is
imperative to achieve value-based care delivery within
an improved healthcare system. The healthcare
reform transitions taking place now and anticipated in
the near future resonate with the educational competencies
and role preparation of the CNL. The purpose
of this article is to review major reforms coming to
healthcare systems and to examine the fit of the CNL
role to lead change during a time of system reform and
transition.
Healthcare Reform and Transitions
Creating an integrated healthcare system that performs
as a seamless system and serves the patient is
the goal of major reform initiatives taking place today.
Expertise in care coordination across the healthcare
continuum is essential for maximum reimbursement
for Medicare and Medicaid patients. Integration of
health services and patient-centered medical homes
are two organizational models poised to provide
patients the right health care at the right time in the
right setting with the best outcome. Payment for value
instead of volume delivered is a major reimbursement
transition coming to the acute care setting necessitating
increased attention to mining the data necessary to
capture quality patient outcomes for maximum reimbursement.
A brief review of these transitions follows.
Integrating the Healthcare System
A major shift in healthcare delivery is the focus on
integrated healthcare services. The concept and definition
of integrated care have been evolving (Cortese
& Korsmo 2009; Kodner 2009) and are now the key
strategies to achieve the quality and value imperatives
of the Patient Protection and Affordable Care Act. Provisions
within the Act identify specific strategies to
achieve patient-centered integrated health care that
and if achieved will provide financial incentives to the
healthcare provider. For example new provisions in
the Act will expand the care coordination in Medicaid
and introduce for the first time care coordination for
Medicare patients (Thorpe & Ogden 2010). Consequently
aging clients with multiple but potentially
preventable chronic illnesses will require more strategic
coordination of care both in and out of the hospital.
Health systems are aligning with physicians and independent
physician practices are aligning practices to
have the optimal opportunity for care coordination
and for providing patients the right care at the right
place (Fisher 2008). Interprofessional healthcare
teams must work together to assure that when the
individual interacts with the system healthcare needs
are quickly identified care is coordinated and a welldefined
follow-up process is in place (Thorpe &
Ogden 2010).
Patient-Centered Medical Homes and Accountable
Care Organizations (ACO)
The healthy home or patient-centered medical
home model provides a coordinated care environment
that assists patients to move through this new integrated
system (Associated Press 2011; Fisher 2008).
The medical home aligns with a primary care practice
is patient-centered and team-driven and serves to
coordinate patients care to receive the most appropriate
care within the most appropriate setting (Cassidy
2010). The use of electronic health records and the
ability to monitor the clinical outcomes of patients are
a key to making such a coordinated effort a success.
The Patient Protection and Affordable Care Act (2010)
outlines that the goal of the patient-centered medical
home is to use health teams to better coordinate and
manage chronic disease as well as decrease hospital
readmissions.
The concept of accountability is an important driver
in healthcare reform reorganization. While the ACO
has received much attention there continues to be a
lack of clarity around the benefits and drawbacks of
becoming a designated ACO (Johnson 2011). An
ACO is responsible not only for care coordination but
also for the quality and costs for a particular patient
population (Rittenhouse Shortell & Fisher 2009).
Not all organizations will meet the qualifications for or
desire to become an ACO as volume and attainment of
care benchmarks must both be demonstrated to
qualify for this designation (Johnson 2011). Additionally
the final decision regarding if an organization
qualifies to become an ACO is made by the CMS not
the organization itself. In all cases accountability
within a high-quality high-value environment
remains a key component for the health system of the
twenty-first century.
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Reimbursing for Value
A major challenge facing healthcare systems will be
to shift from reimbursement for volume to reimbursement
for high performance and quality outcomes.
Beginning in fiscal year 2013 a percentage of Medicare
reimbursement will be withheld unless hospitals
meet benchmark performance measures in outcomes
and patient satisfaction. The percentage withheld is
expected to increase in the coming years but at this
time the increase is unknown. Hospitals can earn
monies back when performance is at or above benchmark
(Lloyd 2011). Measures of care processes
including clinical measures for surgical and cardiac
care and patients satisfaction with their care experiences
have been designated as the primary value indicators
in fiscal year 2013. Additional value measures
including efficiency and outcomes will be tracked in
subsequent years. Measures of patient experiences
include but are not limited to nurse communication
pain management communication about medications
and discharge information. Healthcare analysts
are emphasizing that for hospitals to achieve these
quality outcomes a focus on assuring reliable measures
use of evidence-based practice and skill in care
coordination is needed (Health Care Advisory Board
2010; Huron Consulting Group 2011; Lloyd 2011).
Implications for the CNL Role
The healthcare system changes and reimbursement
models require increased emphasis on care integration
care continuity and delivery of the most effective
evidence-based care for the best value. The integrated
care system requires care providers to possess a
patient-centered focus and skills in care coordination
and experience in interprofessional team care delivery.
Likewise the medical home practice may be seen as a
driver for care integration with one goal being the
decrease in readmissions through interprofessional
care coordination. ACOs and acute care facilities need
care providers who have an understanding of reimbursement
for clinical outcomes evidence-based care
and skills in patient-centered care coordination.
How then can nursing best lead the system
to meet these challenges? The following sections
will describe the preparation of the CNL and outline
why the CNL is a key nursing role possessing the
education and leadership competencies to lead successful
transition in this era of healthcare reform.
CNL preparation roles and current documented
impact will be highlighted.
Current CNL Preparation
While undergraduate education for th
