how does the iom future of nursing report affect nurses in ... · medicaid innovations to improve...
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Title text here
How Does the IOM Future of Nursing Report Affect Nurses in Long-Term Services and SupportsSusan C. Reinhard, RN, PhD, FAANSenior Vice President and DirectorAARP Public Policy InstituteChief Strategist Center to Champion Nursing in America
Long-Term Care ConferenceA Regulatory Perspective and Future Implications
August 23-24, 2011
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Focus
• Key issues in LTSS and what the future may bring
• LTSS State Scorecard in relation to LTSS nurses
• How the IOM Report on the Future of Nursing will
impact this future
• Your leadership
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Key Issues in LTSS and what the future may bring
• Long Term Services and Support rather than Long Term Care
• Overlap with Chronic Care, Transitional Care—Functional Focus
• Movement toward accelerating Home and Community Based Care
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LTSS
• Nurses need to change language to be in tune with
today
• Consumer focused
• Not about the care they get from others as passive
recipients
• It is about services and supports they ideally control
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Key Issues in LTSS and what the future may bring
• Focus on Family Caregivers
• Federal innovations that will affect nurses:
– Integration with Acute, Primary Care
– Managed care
– Duals demonstrations
– CMS Innovation Center
• CLASS Act
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Innovations to Improve Care Transitions and Coordination• Medicare Community-Based Care Transitions Program
• Medicare Independence at Home Demonstration
• Medicare & Medicaid Center for Innovation
• Patient-Centered Medical Home Demonstration
• Community Health Teams for Medical Homes
• Medicaid Health Homes for Chronic Conditions
See Public Policy Institute Fact Sheet: Health Reform Initiatives to Improve Care Coordination and Transitional Care for Chronic Conditions
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Payment Reforms that Support Care Transitions and Coordination
• Hospital Readmission Reduce Incentives (§ 3025)– Penalties for avoidable readmissions
• Accountable Care Organizations (§ 3022)– Medicare Shared Savings Program
– Provider bonuses for saving money and improving quality
• National Payment Bundling Pilot (§ 3023)– Bundled payment for episodes of care
– Physicians, acute hospitals and post-acute care providers
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Medicare Payment Reforms that Support Care Transitions and Coordination
Avoidable Readmission Penalty (§ 3025)
– Incentive to improve care transitions and reduce avoidable readmissions
– Reduced Medicare DRG payments by 1%, rising to 3%
– For certain avoidable readmissions exceeding a threshold (TBD)
– 3 Target conditions TBD starting in FY 2012, 7 in 2015
– Readmission window TBD (ie, 30 days post discharge)
– Hospital-specific readmission rates will be published on Medicare Hospital Compare website
– Expand to skilled nursing homes and HH Agencies
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Innovations to Improve Care Transitions and Coordination
Independence at Home Demonstration (§ 3024)– Starting in 2012 (or sooner), funding of $5 million/5 years
– House Calls to help Medicare beneficiaries remain at home
• Medical Practices (MDs and Nurse practitioners) must have experience delivering home-based primary care, available 24 x 7
• Target Medicare Beneficiaries with Multiple Chronic Illnesses
– 2 or more chronic conditions; 2 or more functional dependencies (ADLs)
– Hospitalized in past 12 months (non-elective)
– Rehab therapy in past 12 months
– Voluntary enrollment of up to 10,000 beneficiaries
– Bonus for savings exceeding 5%
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Innovations to Improve All Care Transitions and Coordination
Community Health Teams (§ 3502)• Interdisciplinary teams contract with Medical Homes
– Collaborate with community support services– Teams must be designated by states or Indian tribes– Chronic care coordination, discharge planning, transitional
care, medication therapy management (§ 3503), mental health referrals, 24 x 7 availability
– HHS grants: ACA does not authorize funding but HHS has indicated funding will be available
• Teams must become self-sustaining in 3 years• Targets patients with chronic conditions regardless of payer type
(Medicare, Medicaid, private)
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Medicaid Innovations to Improve Care Transitions and Coordination
Medicaid Health Homes for Chronic Conditions (§ 2703)– Also known as Medical Homes– State Medicaid Option
• Targets high-risk Medicaid beneficiaries– 2 chronic conditions or– 1 existing chronic condition plus risk of 1 or more
additional or– Serious mental illness
• Services– Enhanced integration and coordination of primary care, acute care,
behavioral care, and long term care– Care management, transitional care, community support services
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Medicaid Innovations to Improve Care Transitions and CoordinationMedicaid Health Homes for Chronic Conditions (cont)
• Funding– Planning grants starting in 2011– CMS will base approval on Letter to State Medicaid Directors, Nov 16,
2010, and subsequent regulations– Matching funds totaling up to $25 million ($500,000 each?)– Over 20 states have expressed interest in planning grants
• Conditions• During first 2 years, 90% federal matching funds for Health Home services
– States must track avoidable readmissions– Estimate savings from care coordination– Report lessons learned
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Duals
• CMS: $1 million per state for 15 states to support design
• Person-centered models that integrate the full range of acute, behavioral health and long-term supports and services
• Does not prescribe managed care per se---CMS open to innovative models
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Acceleration toward more HCBS
• Money Follows the Person
• Balancing grant program
• Community First Option
• CLASS
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LTSS State Scorecard
• Concise performance tool to put LTSS policies and programs in context.
• First attempt to use a multidimensional approach to comprehensively measure state LTSS system performance overall and across diverse areas of performance.
• Differs from analyses that examine a single aspect of states’ LTSS systems.
• Developed over two years—to be released September 8th.
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Partners & Contributors
• Funded collaboratively by The Commonwealth Fund and The SCAN Foundation.
• Experts from across the country formed a National Advisory Panel and a Technical Advisory Panel, which were consulted regularly throughout the development of the Scorecard.
• NCSBN key contributor
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Our Definition of LTSS*
• Inability to perform ADLs or IADLs on one’s own for an extended period (typically 90+ days)
• Includes human assistance, supervision, cueing and standby assistance, assistive technology, health maintenance tasks, information, care coordination
• Includes services used by family caregivers
• In a high-performing system, LTSS are coordinated with housing, transportation, health/medical services
*Those whose LTSS needs arise from intellectual disability or mental
illness are excluded for purposes of the scorecard.17
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Characteristics of aHigh-Performing LTSS System• Support for Family Caregivers
• Affordability and Access
• Choice of Setting and Provider
• Quality of Life and Quality of Care
• Effective Transitions and Organization of Care
– The first four characteristics map to dimensions and indicators
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Dimension: Support for Family Caregivers
In a high-performing LTSS system, the needs of family caregivers are assessed and addressed so that they can continue in their caregiving role without being overburdened.
Support for Family Caregivers includes:
• level of support reported by caregivers;
• legal and system supports provided by the states; and
• the extent to which registered nurses are able to delegate health maintenance tasks to non-family members, which can significantly ease burdens on family caregivers.
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Nurse Delegation Tasks
• Medication administration
i. Oral medication
ii. PRN medication
iii. Pre-filled insulin/insulin pen
iv. Draw up insulin
v. Other injectable medication
vi. Glucometer testing
vii. Medication through tubes
viii. Insertion of suppositories
ix. Eye/ear drops
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Nurse Delegation Tasks
• Tube feedings (Gastrostomy)
• Administration of enemas
• Bladder regimen (intermittent catheterization)
• Ostomy care (skin care, change appliance)
• Respiratory Care
i. Nebulizer treatment
ii. Oxygen therapy
iii. Ventilator care
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State Policies on Delegationof 16 Health Maintenance Tasks
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DATA: National Council of State Boards of Nursing, 2011 Nurse Delegation Survey
SOURCE: State Long-Term Services and Supports Scorecard, 2011NOTE: Data not available for Alabama, Delaware, District of Columbia, North Carolina and Ohio
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Number of Tasks Allowed to be Delegated
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Future of Nursing: Campaign for Action
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Health Care System Challenges
Fragmentation
Health care disparities
Aging and sicker population
Primary care shortage
High costs
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Fragmentation
Lack of integration among providers
System rewards volume, not value
Result: lower-quality care and higher costs
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Health Care Disparities
• Get fewer routine procedures
• Receive poorer care
• Die younger
Racial and ethnic minorities
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Aging and Sicker Population
• Life expectancy rising
• Baby boomers aging
• Chronic diseases increasing
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Primary Care Shortage
• Rural and low-income areas
particularly affected
• Fewer physicians entering
primary care
• 32 million more people to get
health insurance in 2014
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High Costs
Health care costs
unsustainable
Federal budget deficits affected
Wages stagnating
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IOM Report
• High-quality, patient-centered health care for all will require transformation of the health care delivery system
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Health Care Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs,
Not Past Demands
Julie Sochalski & Jonathan Weiner
• A reorganized health care delivery system will have a significant effect on the future roles and responsibilities of RNs and APRNs
Appendix F
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• Innovative Solutions:
• Nursing education funding, emphasis on graduate level
• Medicare GNE Demo
• Prevention and Public Health Fund
• Title VIII of the PHSA
• NHSC
Problem: Chronic and cyclical nursing workforce shortage.
• Innovative Solution: Transitional care pilot program
Problem: Unnecessary re-hospitalizations decrease quality of life for the older adult and drive up Medicare costs.
Opportunities in Affordable Care Act
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• Innovative Solution: Medicare’s Independence at Home Demo
Problem: Too many people in nursing homes and hospitals when they want to be home.
• Innovative Solution: Residency Demo
Problem: Need for nurse practitioners skilled in community-based health centers.
• Innovative Solutions:
• Accountable Care Organizations
• Nurse Managed Health Centers
• Medicare Medical Homes
• Medicaid Health Homes
Problem: Uncoordinated care, lack of communication, too many medications lead to poor outcomes.
Opportunities in Affordable Care Act
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Campaign Vision
All Americans have access to high-quality, patient-centered care in a health care system where nurses contribute as essential partners in achieving success
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Campaign for Action
Education
Practice
CollaborationLeadership
Data
Campaign for Action
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Education
Increase to 80 percent the proportion of nurses with BSN by 2020
Double number of nurses with doctorate by 2020
Implement nurse residency programs
Promote lifelong learning
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Education
Evidence
• Significant association between
educational level and patient outcomes
• 6 percent of AD grads get advanced
degree, enabling them to teach and
serve as PCPs, compared to 20 percent
of BSN grads
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Appendix I
Recommendation 2: Convene expert panels to
develop a model pre-licensure curriculum which:
• can be used as a framework by faculty in
community college-university partnerships
for development of their local curriculum;
• is based on emerging health care needs and
widely accepted nursing competencies as
interpreted for new care delivery models
• incorporates best practices in teaching and
learning
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Practice
• All practitioners should practice to full extent of their education and training
• Optimal care
– Physicians, nurses and other health professionals work in team-based model of care delivery
– Models of care maximize time that providers can spend on their respective roles and responsibilities to patients
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Practice
• Evidence: More than 10 studies show equivalent patient outcomes when care is provided by APRN or MD for certain services
– Includes two Cochrane reviews
– Randomized clinical trial published in JAMA
– Office of Technology Assessment
• No studies show care is better in states that do not allow APRNs to practice to full extent of education and training
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Practice
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Leadership
• Nurses bring important viewpoint to management and policy discussions
• Prepare more nurses to help lead improvements in health care quality, safety, access and value
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Data
Improve health care workforce data collection to better assess and project workforce requirements
• Research on health care workforce is fragmented
• Need data on all health professions
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Diversity
• Nurses should reflect patient population in terms of gender, race and ethnicity
• All nurses should provide culturally competent care
Increase workforce diversity
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Transforming Health Care
cost
quality
access
Education
Leadership
Access to Care
Workforce Data
Interp
rofessio
nal C
ollab
oratio
n
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RWJF AARP
Advisory Committee
Diverse Stakeholders
Policy-makers
Action Coalitions
Communications
Grantmaking
Research, Monitoring, Evaluation
Campaign Strategies
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Campaign for ActionRWJF/AARP seeking support from:
• health professions
• payers
• consumers
• business
• policy-makers
• philanthropies
• educators
• hospitals and health systems
• public health agencies
Nursing must be considered societal issue!
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Campaign for Action
• Long-term alliances
• Field strategy to move key nursing
issues forward at local, state and
national levels
• Expect to be in all states in 2012
• Capture best practices, networking
Action Coalitions
To become part of a coalition, go to: www.thefutureofnursing.org
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UPDATED: 3.24.2011
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Your Leadership
• New models of care require change, including us
• Action Coalitions
– 80/20 competencies
– Scope of Practice (including delegation)
– Leadership on boards and commissions
– Interprofessional education and collaboration
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Campaign Resources
• Visit us on the Web at: www.thefutureofnursing.org
• Follow us on twitter at: www.twitter.com/futureofnursing
• Join us on Facebook at: http://facebook.com/futureofnursing