Healthcare Reform and the Case Manager. Nancy Skinner, RN-BC, CCM. Objectives. Detail financial and regulatory initiatives that impact the current practice of case management.
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Healthcare Reform and the Case Manager
Nancy Skinner, RN-BC, CCM
The Affordable Care Act (ACA)
Balancing access, quality, safety and cost!
“It's about better care: care that is safe, timely, effective, efficient, equitable and patient-centered.”
O’Reilly, K. Health Reform Law Will Boost Care Quality. Amednews.com.
“Americans go the hospital to get well, but millions of patients are injured because of preventable complications and accidents. Working closely with hospitals, doctors, nurses, patients, families and employers, we will support efforts to help keep patients safe, improve care, and reduce costs. Working together, we can help eliminate preventable harm to patients.”
Establishing the Goals
On March 22, 2011, the U.S. Department of Health and Human Services released its National Strategy for Quality Improvement in Health Care (National Quality Strategy). The Affordable Care Act required the Secretary of HHS to establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. This strategy is designed to guide federal, state, and local health initiatives.
The National Quality Strategy establishes three broad aims: Better Care, Healthy People/Healthy Communities, and Affordable Care.
Six Strategies to Advance these Aims
Coordinated Team Approach
Patient and Family Centered Care
Transitions of Care
Over half the funding of ACA, which will cost anestimated $938 billion over 10 years, comes from reductionsin Medicare payments to hospitals and other nonphysician providers.
Improving The Quality & Efficiency of Care
Partnership for Patients
Partnership for Patients: Better Care, Lower Costs is a program that "will help save 60,000 lives by stopping millions of preventable injuries and complications in patient care over the next three years” according to a Department of Health and Human Services statement.
Through the initiative, major hospitals, employers, healthcare providers, patient advocates, and government officials will work together toward two main goals: preventing harm in hospitalized patients and helping patients heal without complications.
Partnership for Patients will begin by focusing on nine kinds of medical errors and complications, including adverse drug reactions and pressure ulcers.
Aligned payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately. Bundled payments will give doctors and hospitals new incentives to coordinate care, improve the quality of care and save money for Medicare.
“Patients don’t get care from just one person – it takes a team, and this initiative will help ensure the team is working together,” said HHS Secretary Kathleen Sebelius. “The Bundled Payments initiative will encourage doctors, nurses and specialists to coordinate care. It is a key part of our efforts to give patients better health, better care, and lower costs.”
Funds a package of services patients receive to treat a specific medical condition during a single hospital stay and/or recovery from that stay – this is known as an episode of care. By bundling payment across providers for multiple services, providers will have a greater incentive to coordinate and ensure continuity of care across settings, resulting in better care for patients. Better coordinated care can reduce unnecessary duplication of services, reduce preventable medical errors, help patients heal without harm, and lower costs.
The Bundled Payments initiative is being launched by the new Center for Medicare and Medicaid Innovation (Innovation Center), which was created by the Affordable Care Act to carry out the critical task of finding new and better ways to provide and pay for health care to a growing population of Medicare and Medicaid beneficiaries.
“This Bundled Payment initiative responds to the overwhelming calls from the hospital and physician communities for a flexible approach to patient care improvement,” said CMS Administrator Donald Berwick, M.D. “All around the country, many of the leading health care institutions have already implemented these kinds of projects and seen positive results.”
This initiative is based on research and previous demonstration projects that suggest this approach has tremendous potential. For example, a Medicare heart bypass surgery bundled payment demonstration saved the program $42.3 million, or roughly 10 percent of expected costs, and saved patients $7.9 million in coinsurance while improving care and lowering hospital mortality.
“From a patient perspective, bundled payments make sense. You want your doctors to collaborate more closely with your physical therapist, your pharmacist and your family caregivers. But that sort of common sense practice is hard to achieve without a payment system that supports coordination over fragmentation and fosters the kinds of relationships we expect our health care providers to have,” said Dr. Berwick.
A Snapshot Of Quality
A Gauge for the Future
Requirements for Medication Therapy Management Programs (MTMP): Under 423.153(d), a Part D sponsor must have established a MTM program that:
Journal of the American Board of Family Medicine (www.ncbi.nlm.nih.gov/pubmed/21551394).
Provisions for Care Coordination
Crossing the continuum of care
Care coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time.Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.
National Quality Forum (NQF) - ENDORSED DEFINITION AND FRAMEWORK FOR MEASURING CARE COORDINATION
No Margin = No Mission.
In a post-ACA world, the healthcare case manager is a cornerstone of care delivery.
How will we accomplish?
Many "naive policymakers, out-of-touch regulators, inflexible legal experts and physician-leader apparatchiks" contend primary care physicians can manage all the elements of an ACO. JaanSidorov, MD, publisher of ACO Watch and The Disease Management Care Blog, disagrees. "Docs don't mind being ultimately responsible, but they have little interest in reviewing, recruiting or educating lists of patients. They are happy to delegate such tasks to case managers. In other words, the case managers will be the linchpin to ACO success." (ACO Watch)
On a recent flight, I heard
“Welcome aboard Flight 5322 to Atlanta. To operate your seat belt, insert the metal tab into the buckle, and pull it tight. It works just like every other seat belt; and, if you don't know how to operate one, you probably shouldn't be out in public unsupervised.”
Patient Family Caregiver
The most important team members
Physicians Through each Transition of Care
Working in Partnership with the Patient in Directing the Team!
Can we say that all team members develop and maintain this quality?
PCMH and ACO’s
Some of the Alphabet Soup of ACA
The Future as I See It!
View Transitions of Care As a Process Not An Event
The Essential Components of Care Coordination include:
That Impact Effective Transitions of Care
Components Essential To Every Initiative
“Transitions Of Care According to Nancy”
National Transitions of Care Coalition (NTOCC) Measures Workgroup. Transitions of care measures. 2008.
Care Coordination Begins at or before Admission
Success of the Multi-Disciplinary Teams
Will depend upon:
Four Basic Principals of Motivational Interviewing: R-U-L-E, Glovsky, E., MI Institute, Jan 2011
Transitioning The Continuum of Care with Bi-Directional Communication
Assessment & Support
Behavior Health Change
Coordination & Care Plan
Assessment & Support
Assessment & Care Plan
Patient/Client Education within the Care Coordination Plan
Communication is the Key!