As the U.S. transitions to a value-based care delivery system, nurses play a key role in accountable care organizations, coordinating patients care, conducting holistic assessments and intervening to boost adherence to care plans to, ultimately, improve patients outcomes.
“Theres a need for nurses who are willing to partner with us and anyone else to move our country forward,” said Purity Nyaga, RN, MSN, director, clinical ACO at Methodist Health Systems Methodist Patient-Centered Accountable Care Organization in Dallas. “In the future of healthcare, theres a high need for care coordination.”
Colleen Holliday, RN, BSN, MSA, an ACO beneficiary care navigator at Methodist, looks for opportunities and organizations that are forward thinking. The ACO is the latest opportunity. “Im an innovator at heart and healthcare has benefited from those who are not afraid to change the status quo and look for better ways of assisting patients,” Holliday said. “What I do is very worthwhile and the relationship-based care, going forward, is one that will proliferate in the healthcare arena.”
Being in on the ground floor of a new care-delivery model requires nurses to be flexible, added Nicole Eule, RN case manager at Collaborative Care of Florida, an ACO that includes Orlando Health and Physician Associates. “You have to be able to think fast and change as things are changing,” Eule said. “Its exciting being part of something new.”
ACOs share the common goal of achieving better outcomes at lower cost and with an improved patient experience. Private insurers, such as Cigna, have found success with the model. The Centers for Medicare & Medicaid Services developed the Medicare Shared Savings Program and will split any savings realized by ACOs that reduce the growth in healthcare costs, yet meet quality performance standards and put patients first. Methodist and Collaborative Care participate in the program.
Shelly Rice, RN, BSN, a care coordinator at Collaborative Care, said, “You have to be comfortable in the gray areas. We find it exciting and feel we are setting the bar for the new delivery model.”
Nurses in both ACOs focus on coordinating care of patients at greatest risk of a disease exacerbation or readmission to the hospital. But how they go about it differs. Methodist has stratified risk and assigned patients a level from one to six, with one at minimal need for intervention and six in greatest need because of comorbidities and a history of frequent admissions or ED visits, Nyaga explained. BSN-prepared RN ACO beneficiary care navigators work with patients at levels five and six. RN population health managers focus on levels three and four patients, and LVNs or medical technicians teach preventive care to low-risk patients.
All of the nurses are experienced in chronic disease management, geriatrics, and public or population health. Holliday has a varied background that includes long-term care management, home health, hospice and acute care. “All those roles tied together gives me a keen assessment eye, flexibility and adaptability, which are important as I work with these different situations,” she said. “I use everything in my nursing career in this role.”
Methodist care navigators and population health managers meet patients in the hospital and follow up when they go home or to a nursing home. They complete a medication reconciliation, ensure the person has follow-up appointments and educate in self-care. Every day differs and brings new opportunities. “I look for the most critical issue and prioritize from there,” Holliday said. “That may be utilities ready to be shut off or medication reconciliation.”
Or it may require arranging for a house cleaning or obtaining medical equipment. “Every case is different,” Holliday said. “Its a challenge to go in and help [patients] help themselves.”
Collaborative Care nurses share that same observation and goals, but they telephonically manage and conduct individual and group classes at providers offices. Rice came from a workers compensation case management background and said she finds her new role rewarding, as does Eule, who came from critical care, med-surg and home health. “I dont think I could do this without my experience on the floor as an RN,” Eule said. “You need the clinical judgment, being in tune with the patient and red flags, and [know the] steps to take.”
The nurses become a line of communication after discharge. They build rapport at the first call. “Were always assessing our patients and planning their care based on their individual needs,” Rice said. By “educating our patients we are empowering them to take responsibility for their healthcare.”
The nurses use risk stratification tools and population health management software to identify gaps in care and advise identified patients to contact their providers, which saves the nurses time.
“Theres nothing better than an educated patient who is not afraid to ask questions,” Eule added. “Our goal is to empower the patients, lower costs and reverse some disease states.”