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Clinicians can lead the shift to value-based care

Clinicians are the face of healthcare. We interface with patients, care for them, engage their families and we are a go-to resource in day-to-day treatment. This makes us great patient advocates as we partner with patients and families in their care.

As healthcare shifts to value-based practices, nurses are well positioned to lead the charge in creating better patient outcomes without placing undue strain on the system. One solution lies in optimizing care coordination.

The shifting landscape from fee-for-service to value-based care

Heather O'Sullivan, MSN, AGPCNP-BC

Heather O’Sullivan, RN

Historically, fee-for-service reimbursement has driven most care decisions, but with the industry now emphasizing quality over quantity of care, models are changing and practices are shifting. Increasingly, providers are being held accountable for maintaining collaborative, seamless care coordination across the continuum and nurses on the front lines are well-equipped to drive more efficient practices.

For example, nurses can facilitate more comprehensive care transitions, particularly between acute and post-acute care. Transitions to post-acute facilities have historically been a driver of expensive and highly variable care.

In fact, 73% of the variance in Medicare spending per beneficiary is attributable to post-acute care. Poor handovers during a transition often lead to increased medical errors, higher re-admissions, more frequent acquired infections and dissatisfied patients.

In order to engage in efficient transitions for patients, a certain level of customer service is required. Patients and their families need to understand the care plan, determine potential pitfalls (like medication reconciliation) and run through scenarios, both to gain peace of mind and prevent re-admissions.

By spending time with a patient’s family explaining the process and clearly articulating expectations, nurses in acute and post-acute facilities can affect better long-term outcomes.

But a few barriers stand in the way.

Mary Beth Kingston, MSN, RN, NEA-BC

Mary Beth Kingston, RN

How to overcome common barriers to care coordination

To optimize care transitions and create a more positive experience for patients, clinicians must combat several systemic breakdowns in the continuum.

  • Poor communication — Whether among providers or between the patient and a provider, communication can fall short, particularly during care transitions. In a value-based environment, discharge doesn’t absolve a discharging provider of responsibility. Nurses are positioned to provide a coordinated and warm handover when a patient moves between facilities. They must think proactively about the patient’s journey and clearly communicate a care plan and expectations to the patient and their family to identify possible pitfalls and establish lines of communication once the patient is discharged home.

    A patient’s needs may change at different points during recovery, so it’s critical to communicate with providers across the continuum to ensure everyone is aligned with the protocol.

  • Relationship shortages — Instead of waiting for providers and community organizations to develop partnerships, nurses can start building their own networks to support patients and ensure they have the appropriate resources through each stage of their journeys. Look to providers who are achieving optimal patient outcomes and seeing fewer re-admissions. Like-minded people and organizations are easily recognized by the questions they ask and results they produce. Formal relationships with high-performing organizations will facilitate consistency in communication and coordination.
  • Outdated or incompatible technology — EHRs often are not interoperable across all providers and, in some cases, providers are still using fax machines, phone calls and even sticky notes to coordinate care. Tools (and processes) must be upgraded for true efficiency across the continuum. Nurses should advocate for new technologies that embed naturally into workflows. Some platforms leverage data to track performance and can help influence care decisions in real time and establish or improve a standardized method of care across the continuum.
  • Hidden issues — There’s one other potential complication hiding in plain sight: the individual patient’s social determinants of health.

    Lack of transportation or childcare, homelessness, poor nutrition, lack of access to community resources, isolation and other factors outside the four walls of the hospital can hinder a patient’s recovery and increase their chances of re-admission.

    If nurses know about these variables up front, they can better guide treatment and arrange for the appropriate resources to be in place upon discharge. You just need to know which questions to ask.

The role of the nurse

As nurses we’re not only patients’ caretakers, but we also often are their No. 1 advocate. We must give patients and their families a voice to get the best, most effective treatment possible across the continuum and work to improve the processes and resources we have at our disposal to help them, especially during transitions.

That’s the only way value-based care will truly succeed in making a critical impact on healthcare and ultimately improving care for the patients we serve.


Check out these courses on caring for patients

A Nurse’s Guide to Transition-of-Care
(5 contact hours)
Transition of care refers to a patient leaving one care setting and moving to another care setting or to home. All patients have care transition needs, some being more complex than others. This course is designed to give the nurse an understanding of care transitions that will help him or her better meet each patient’s needs. The course includes a history of care transition planning, the role of the transition planner, resources, professional attributes, accountability and external resources.

Empathy 101 for Nurses: How to Care for Yourself While Emotionally Supporting Others
(1 contact hour)

Mary Beth Kingston, MSN, RN, NEA-BC, and Heather O'Sullivan, MSN, AGPCNP-BC
Heather O’Sullivan, MSN, AGPCNP-BC, is the chief clinical officer at naviHealth and is based in the Boston area. She has two decades in clinical, operational, and leadership roles, serving hospitals and health systems, health plans and home healthcare providers. O'Sullivan is responsible for directing naviHealth’s centralized clinical design and operations. Mary Beth Kingston, MSN, RN, NEA-BC, is the CNO of Advocate Aurora Health and is president elect of AONE. Kingston, who is based in Milwaukee, Wis., has served in a variety of administrative and clinical roles, as well as a number of community board roles.

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