By Susana Hall, RN, MBA, Clinical Director
As a nurse who has spent 20 years working with patients to deliver high-quality, coordinated care at the right time and in the right setting, nothing excites me more than the opportunity that value-based care offers nurses and nurse leaders to better help and care for patients today.
Care redesign – the goal of all value-based care models, whether population health or episodic in nature – is about merging quality patient care and exceptional business performance to provide better outcomes for patients and their families. For years, Medicare patients handed hospitals their Medicare Benefits card and trusted them to spend their benefits wisely. Value-based care models now require us to help adjudicate these benefits and utilization more closely.
Nurses and nurse leaders can make value-based care a reality for patients every day. We are key frontline resources in many care settings, and we have an amazing ability to drive patient outcomes and experience. Through our work, we have played a role in the success of CMS’ value-based programs such as the Bundled Payments for Care Improvement (BPCI) initiative and Accountable Care Organizations (ACOs), and they can continue driving success in future initiatives, such as BPCI Advanced and the pending Patient-Driven Payment Model (PDPM). We also will play a role as commercial payers and employers adopt value-based models.
The nurse’s impact all begins with one simple question to the patient: “What matters to you for your recovery?” This question allows everyone to slow down, think about personal healthcare goals, and establish clear communication, so that patients and their families, along with nurses and clinical teams, can plan together. For many patients, getting home safely and quickly is a critical component of their goals.
Two important factors underscore the need for nurses and nurse leaders to drive the right discussions with their patients:
- There is going to be an increase in the number of older, sicker people.
By 2029, baby boomers will comprise 73% of the 65-and-over population. Over 30 million of them will be managing serious chronic health issues. Patients with chronic conditions account for 81% of hospital admissions, 91% of prescriptions filled, 76% of all physician visits, and more than 75% of home visits.
- Patients do better when they recover at home.
Patients recovering at home are less vulnerable to “complications of confinement in hospitals such as delirium, skin conditions and falls,” according to an article published by The New England Journal of Medicine. Additionally, the emotional benefits of returning home can be significant: one study found greater satisfaction with home care than acute hospital-inpatient care for patients and their family members.
When at home and in familiar environments, patients recover better and have a decreased chance of a downward spiral that may lead to readmissions. For these reasons and more, nurses can advocate for and help patients manage their health, get out of hospitals sooner, and develop plans that keep patients from readmitting. Helping patients to engage in self-management activities and maintain their lifestyle as much as possible is critical. With that one simple question, nurses can change the focus from the provider to the patient.
Along with determining what matters to the patient in terms of recovery, there are many other key activities that nurses ー and other caregivers ー should undertake:
- Identifying caregiver(s) availability and capability.
- Assessing, monitoring and addressing what the patient will need in order to recover successfully at home.
- Evaluating how the patient responds to an early mobility program.
- Reviewing clinical needs and using teach-back methods with the patient, family and caregiver.
- Identifying the 3-4 top concerns that need to be carefully monitored during the initial transition period.
Below are anecdotes that demonstrate the power of this approach:
- A man with congestive heart failure (and a frequent utilizer of the hospital setting)
When asked what mattered most to him in his recovery, he replied, “to work in my garden every day.” The result: The care team developed a plan where he learned how to monitor his weight, fluids and diet, as well as when to contact his cardiologist (i.e., if his weight increased). He stopped having to be hospitalized, and started delivering vegetables to his neighbors. - A woman who underwent knee-replacement surgery
When asked what she wanted from her care, she said, “I don’t want to be a burden on my family. I want to be able to make my own lunch and carry it myself.” The nursing and therapy staff worked with her on how to effectively use a walker with adaptive pockets, and she went home with her family the next day.
Where to start?
Nurses can inform and teach patients how to have a successful transition and recovery at home. Nursing leaders can model this behavior by developing and monitoring early mobility protocols, supporting staff during professional rounds when they feel that a patient can go home if they get the right support in the inpatient setting, and engaging nursing teams to develop new approaches and methods that support home-based recovery.
If you are looking for a way to begin, the Remedy Partners’ Care Innovation Institute (CII) is a resource that offers best practices in transitional care for payers and providers. You can find checklists and materials that identify specific roles and strategies for care teams to achieve a high-value transition. You will also find resources that will help you in supporting a patient’s return to independence in the least restrictive setting appropriate to their needs.
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