CMS value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support the three part aim of (1) better care for individuals (2) better health for populations and (3) lower cost.
There are transformative changes occurring in healthcare for which nurses, because of their role, their education, and the respect they have earned, are well positioned to contribute to and lead. To be a major player in shaping these changes, nurses must understand the factors driving the change, the mandates for practice change, and the competencies (knowledge, skills, and attitudes) that will be needed for personal and systemwide success.
Not surprisingly, and by design, value-based payment policies have prompted interventions designed to improve the bottom line of health care organizations that stand to lose or gain from achieving the targeted outcomes. Nursing is a fundamental driver of both outcomes and costs in most health care organizations. Nurses contribute to creating value in health care as 1) a key structural component in the provision of health care services, and 2) leaders and innovators in improving processes and the organizational environment in which health care services are delivered. In the following sections, we review the evidence of value for each of these roles.
Nursing education is unique in its dual focus on individual care, as well as population health and community nursing. Nurses are trained to consider the individual, family and community in evaluating clinical interventions by advocating for patients, providing education and supporting patients in their ability to self-manage their health
One of nursing’s key roles is to plan, operationalize and evaluate the impact of the plan of care. It makes sense, then, that nursing should play a central role in understanding social determinants of health at the individual, community and population level. Through their interaction and advocacy for patients, nurses contribute to patient outcomes and population health management results.
The necessary skill set for value based care initiatives is much broader than what was needed just a decade ago, according to Lamont Yoder—CEO of Banner Gateway Medical Center and Banner MD Anderson Cancer Center in Gilbert, Arizona—and Carol Bradley, SVP and CNO of Legacy Health in Portland, Oregon. As providers face increasing pressure to improve outcomes while cutting costs, “nursing leaders need to have the business acumen to analyze the way care is being delivered and apply clinical value analyses and the kind of ‘lean’ thinking that can reduce waste, inefficiency, and costs,” Bradley said.
The use of standard measures plays two key roles: First, it provides a mechanism to efficiently recognize circumstances that may modify conditions and treatment plans. Second, it makes the information usable by various systems and health care providers for various purposes.
The Institute of Medicine has recommended 12 measurement domains of social determinants that have a potential to be used for improved patient care and population health management, and that can be consistently collected and shared. Those domains include health behaviors (alcohol use, tobacco use and exposure, physical activity), social factors (intimate partner violence, social connections and social isolation, stress, depression) and socio-demographics (census tract-median income, education, financial resource strain, race and ethnicity).
Understanding the influence of social determinants on populations
To excel in population health management, an organization must understand how individual characteristics and contextual factors, external to the care delivery process, impact a population’s health. Nursing serves a central role in population health management, thanks to the various patient touch points during a clinical encounter within a community, ambulatory or inpatient setting.
Consider an individual who is obese, suffers from hypertension and has a prescription for an antihypertensive medication, but doesn’t take their medication. Is this due to inability to purchase medication? Does the patient not understand the long-term effects of hypertension on their health? Does the patient have transportation barriers around picking up their prescription? These examples are linked to different health determinants. Individual characteristics may necessitate different health interventions or resources. Moreover, the interaction of the characteristics may drive how an intervention is applied.
Empowering nurses to be advocates for community-integrated health
Linking people in need to available community resources is an important aspect of addressing the effects of social determinants.
Health care delivery is evolving and will continue to evolve. It’s no surprise, then, that the nurse’s role will evolve from more traditional bedside or office nursing to community outreach via phone, home visits, interdisciplinary collaboration or involvement in community collaboratives, all with the goal of improving a community’s health.