ealthcare organizations and providers areexperiencing unprecedented change as the

industry paradigm shifts from volume-based,fee for service to data-driven, value-based service.

Although there are divergent opinions regarding how bestto decrease cost and improve quality, there is little dis-agreement that the American healthcare system is tooexpensive, and interventions to bend the cost curve areimperative to lower Medicare spending and future deficits.

The Patient Protection and Affordable Care Act, com-monly called the Affordable Care Act, or ACA, becamelaw in March 2010. The 2 principal aims of this legislationare to decrease the number of uninsured Americans andreduce the overall cost of care. Nurses can play a signifi-cant role in both increasing access and providing high-quality, more affordable care.1 Recognition of the value ofnurses’ work as primary care providers, case managers, andcare coordinators will increase, and if a job descriptionrequires a nurse, the work, by definition, is nursing.Regardless of reporting structures, chief nursing officers(CNOs)/chief nurse executives (CNEs) retain and main-tain authority for nursing practice and standards of care inaccordance with The Joint Commission standards.

Among the reforms aimed at improving outcomes andstreamlining the delivery of healthcare, accountable careorganizations (ACOs) are a new organizational form inwhich coordinated groups of hospitals, physicians, andother providers voluntarily come together to providehigh-quality care to a group of Medicare patients.2 AnACO can also be described as “an interprofessional andpatient-centered model that provides significant providerincentives to coordinate and integrate care with a focuson improving the quality of care for patients.” (L.Q.Everett as quoted in Watson, 2013).3

ACOs are shared-savings organizations in which thebusiness plan is to reduce the cost of care per memberper month by keeping patients healthier through carefulmanagement and coordination of services across the carecontinuum. As 1 example, an interprofessional team com-posed of a primary care physician, an advanced practiceregistered nurse (APRN), a pharmacist, and a dieticianmay work with a population of heart failure patients tosuccessfully transition from acute hospitalization in stablecondition, and monitor and manage their treatment regi-men of medications, diet, and activity to prevent readmis-

sions and emergency department (ED) visits, both veryhigh-cost interventions.

New payment mechanisms are proposed, such as bun-dled payments in which an ACO will receive 1 paymentfor a patient’s care and have to divide it among the differ-ent providers. There is discussion of at-risk arrangements,which means that an organization is paid a certainamount per patient per month, and if providers can keeppatients healthier, requiring fewer intensive interventions,the providers make more, but if patients’ care cost more,they are at risk to lose money.

Case and care management across the continuum is farfrom a new concept in nursing. Phyllis Ethridge’s work atCarondelet St. Mary’s in Tucson, Arizona, in the 1980srepresents a seminal demonstration of the value of contin-uum-based nursing practice and care.4 Lack of reimburse-ment for case management services posed a significantbarrier to replication and dissemination of this model.

Nurse executives are well positioned to provide system-level thinking and leadership in integrated care manage-ment and patient care coordination across systems of care.3,5

They have the leadership, business, and coordination of careacumen to work in collaborative, shared leadership rolesacross the continuum of care. Nurse clinicians have thenecessary knowledge and skill set to competently providethe core transitional care management and care coordina-tion services essential to the success of ACOs.

PAYMENT FOR TRANSITIONAL CAREMANAGEMENT AND CARE COORDINATIONThe 2013 Medicare Physician Fee Schedule update includesnew payment codes for which the Centers for Medicare &Medicaid Services (CMS) will, for the first time, providedirect Part B reimbursement for transitional care manage-ment (TCM) to nurse practitioners, clinical nurse specialists,and certified nurse midwives.6 TCM includes a primary careprofessional contacting the patient soon after discharge,conducting an in-person visit, engaging in medical decisionmaking, and providing care coordination.7

New codes and payments were also approved for com-plex chronic care coordination (CCCC), but CMS chose toinclude CCCC as part of a broader bundle of servicesrather than paying for it separately. CCCC includes effec-tively communicating and delivering a patient’s needs andpreferences for healthcare services and information across a

H

AONE Position Paper:Nursing Practice and Payment

in ACOsMary Crabtree Tonges, PhD, RN, FAAN

www.nurseleader.com Nurse Leader 25

26 Nurse Leader December 2013

continuum of care.8 Registered nurses can provideCCCC, and although CMS can’t be billed separately,private insurers may decide to use these codes in theirreimbursement policies.6 Because ACOs will integratethe services of physicians, hospitals and other providers,billing for Part B work will be part of their administra-tive infrastructure.

Brewer (2013)9 suggests: Nurses don’t need toexpand their roles to take their place in the evolvinghealthcare system. Nurses understand communitiesand health, and how to navigate and transition patientsthroughout the healthcare system to effect betteroutcomes, but the role has not been rewarded in thehealthcare financial system.

The initiation of direct reimbursement for corenursing services by CMS represents significant publicrecognition of the value and importance of nurses’work. The Institute of Medicine’s landmark 2010report The Future of Nursing: Leading Change, AdvancingHealth includes recommendations that nurses shouldbe full partners with physicians and other professionalsin redesigning our healthcare system and that nursesshould practice to the full extent of their educationand training.10 The advent of CMS providing directreimbursement for nursing services signals progresstoward implementation of these recommendations.

THE BUSINESS CASE FOR NURSE-LEDINITIATIVESThere are many reports of innovative, nurse-led initia-tives that demonstrate success in increasing access,improving quality, and reducing cost.10,11 The EleventhStreet Family Health Services, affiliated with DrexelUniversity College of Nursing and Health Professions,provides access to comprehensive, trans-disciplinary carefor residents of public housing communities and othervulnerable populations in Philadelphia.12 The impact ofthis program is demonstrated in outcomes such asimproved quality of life for patients participating in thefitness program, as measured by the 36-Item ShortForm Health Survey (SF-36) with a significant increasein perceived health status at 3, 6, and 12 months;decreased unnecessary specialty workups for childrenwhose issues are family/behaviorally based (e.g., enure-sis) through the integration of a pediatric behavioralhealth consultant; and increased use of self-care plans forpatient with chronic illness to 100%, as well as increasedpatients' self-efficacy through the Living with ChronicIllness program.12 The Family Health and Birth Centerin the Developing Families Center, Washington, DC, isanother example of the impact nursing has made inleading interdisciplinary medical homes.13 Evidence of

success includes the following comparisons for patientsat the Center and African Americans in Washington DC:a 5% preterm birth rate compared to 15.6%, 3% lowbirth weight compared with 14.5%, and 10% cesareansection rate compared to 31.5%.13 In the Program ofAll-Inclusive Care of the Elderly (PACE), nurses andother health professionals provide comprehensive, com-munity-based care that enables frail seniors to avoidexpensive nursing home placement, yielding a 48%reduction in cost (average annual charge for privatenursing home care � $69,715 vs. average annualMedicaid payment per enrollee in PACE � $36,000).11

CHALLENGES AND OPPORTUNITIES FORCNOS/CNESThe advent of ACOs in which APRNs and othernurses may report elsewhere raises the question, “Whoowns nursing?” As leadership partners in interprofes-sional practice, CNOs/CNEs are equal players at thetable, leading and directing no matter where nursing ispracticed. Regardless of line authority and reportingstructures, nursing practice and standards continue tofall within the scope of the most senior nurse leader’sresponsibilities. Hoying (2013)14 describes a model inwhich the role of the CNO has expanded beyondresponsibility for nursing on the inpatient units andallied health professionals to encompass the outpatientsetting, urgent care sites, satellite locations, and homecare. The CNO is accountable for the delivery ofnursing care across the continuum, and all of nursinghas a direct-line reporting relationship to this position.In this model, assistant vice presidents reporting to theCNO oversee a service, such as mental health, acrossthe continuum, and staff nurses rotate through theinpatient and outpatient areas instead of having sepa-rate clinic positions.

Better population health management is essential tothe success of ACOs, and data-driven quality measure-ment and performance analysis are essential to high-quality patient care. Population management dashboardswill capture the monitoring and measurement indices ofthe efficiency and effectiveness of nurse deployment.Data linking nurses’ independent and dependent actionswith desired outcomes will be required to substantiatethe attribution of savings and better quality to nurses’work. In addition to decreased readmissions and EDvisits, such outcomes could include avoidance of unnec-essary testing, prescription of the most cost-effectivedrugs, and appropriate end of life care.

As part of the implementation of the ACA, HealthInsurance Exchanges will serve as: a mechanism fororganizing the health insurance marketplace to help

Nurse Leader 27www.nurseleader.com

consumers and small businesses shop for coverage in away that permits easy comparison of available planoptions based on price, benefits and services, andquality.15

Exchanges could lead to narrower networks thatinclude only those organizations that can demonstratethe provision of high quality, less costly care, andexcellent outcomes.

RECOMMENDATIONS1. Recognize the opportunity and need to advo-

cate for standards in all patient care areas inwhich nurses practice across the continuum.

2. Be cognizant of initiatives to extend care across awider continuum and take a leadership role inthis work, such as, but not limited to, manage-ment of transitions of care, prevention of read-missions, and population health management ofchronic illness.

3. Consider the case for a CNO/CNE positionwith line authority for nursing across the contin-uum on the basis of better continuity of care andmeeting The Joint Commission standards.

4. Ensure that there is at least a matrix relationshipbetween the CNO/CNE and APRNs and out-patient nursing depicted in the organizationalchart and operationalized.

5. Strengthen communication and working rela-tionships between and among inpatient, outpa-tient, home care, and advanced practice nurses.

6. Create a center for advanced practice providersto address consistency in job descriptions, privi-leges, orientation, and continuing education anddevelop a shared governance model and profes-sional community for APRNs.

7. Stay current with changes in healthcare law, poli-cy, and payment, as well as technologies that willsupport better population health management.

SUMMARYNurse executives are a logical choice for leadershiproles in ACOs, and the consistent provision of TCMand CCCC services by nurse clinicians holds greatpromise for reducing readmissions and helpingchronically ill patients stay healthier. In the bestinterest of patients and families, AONE urges nurseexecutives and clinicians to recognize and addressthe challenges, while embracing the opportunitiescreated by implementation of the ACA to lead,positively influence, and contribute to a healthiertomorrow for our country, fulfilling our profession-al social contract.

References1. American Nurses Association. The Value of Nursing Care

Coordination: A White Paper of the American Nurses Association.June 2012. http://www.nursingworld.org/carecoordinationwhitepaper.

2. Centers for Medicare & Medicaid Services. Accountable CareOrganizations (ACO). March 2013. http://www.cms.gov/Medicare/Medicare-Fee-For Service-Payment/ACO/index.html. AccessedOctober 18, 2012.

3. Watson CA. Understanding accountable care organizations: aninterview with Linda Q. Everett, PhD, RN, NEA-BC, FAAN, execu-tive vice president/chief nurse executive, Indiana University Health,Indianapolis, IN. Voice Nurs Leadersh. 2013;11(2):12.

4. Ethridge P, Lamb GS. Professional nursing case managementimproves quality, access and costs. Nurs Manage. 1989;20(3):30-36.

5. Ritter-Teitel J. Evolving forms of accountable care organizations:implications for nurse leaders. Nurse Leader. 2012;10(6):36-38.

6. American Nurses Association. (2013). Medicare/Transitional CareManagement. http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/Issue-Briefs/Care-Coordination/MedicareTransitionalCareManagement. Accessed .

7. Lansey D. Variety of coding changes loom for 2013. ACP Internist.November/December 2012. http://www.acpinternist.org/archives/2012/11/coding.htm.

8. American Nurses Association. New Medicare provisions to recog-nize and pay for core nursing services. [Press release]. November15, 2012. http://nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2012-PR/Medicare-Recognize-Pay-for-Core-Nursing-Services.pdf.

9. Brewer .What’s the state of nursing in 2013? March 9, 2013.Buffalo News. http://www.buffalownews.com/apps/pbcs.dII/artcle?AID�201309/BUSINESS/13039144.

10. Institute of Medicine. The Future of Nursing: Leading Change,Advancing Health. Committee on the Robert Wood JohnsonFoundation initiative on the future of Nursing. Washington, DC:Academy Press; 2010.

11. Robert Wood Johnson Foundation. Nursing’s Prescription for aReformed Health System: Use Exemplary Nursing Initiatives toExpand Access, Improve Quality, Reduce Costs, and PromotePrevention. Chart Nurs Future. March 2009. http://www.aannet.org/assets/docs/RaisetheVoice/rwjf_charting%20nursing%20future_mar09.pdf.

12. American Academy of Nursing. Raise the Voice. The EleventhStreet Family Health Services, Drexel University. 2013.http://www.aannet.org/edge-runners--eleventh-street-family-health-services.

13. American Academy of Nursing. Raise the Voice. Family Health andBirth Center in the Developing Families Center. http://www.aannet.org/edge-runners--family-health-and-birth-center-in-the-developing-fami-lies-center.

14. Hoying C. The role of nurse leaders in primary care. Nurse Leader.2013;11(3):21-22.

15. Centers for Medicare & Medicaid Services. The Center forConsumer Information & Insurance Oversight. Initial guidance tostates on exchanges. http://www.cms.gov/CCIIO/Resources/Files/guidance_to_states_on_exchanges.html. Accessed April 26, 2013.

Mary Crabtree Tonges, PhD, RN, FAAN, is senior vicepresident of Nursing Administration at the University ofNorth Carolina Hospitals, Durham, North Carolina. Shecan be reached at aone@aha.org.

1541-4612/2013/ $ See front matterCopyright 2013 by Mosby Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2013.10.006