The role of nurses in new incentive-based hospital payment models Olga Yakusheva, Ph.D. University of Michigan

Outline Conceptual framework Value-Based Purchasing (VBP) Program Targeted outcomes Financial implications VBP-targeted outcomes, nurse sensitive outcomes What can be done to improve hospital performance through nursing?

Introduction Value and healthcare reform; role of hospitals Center for Medicaid and Medicare Services (CMS): Value-Based Purchasing (VBP) program Hospital-Acquired Conditions (HAC) reduction program Hospital Readmissions Reduction Program *Reimbursement tied to outcomes and costs* Many of the outcomes are endorsed by National Quality Forum (NQF) as nursing-sensitive

Conceptual Framework National Database of Nursing Quality Indicators (NDNQI) Targeted by CMS Nursing- sensitive Outcomes Nurse-sensitive & targeted by CMS Structure Process Intersection of NDNQI indicators and CMS-targeted outcomes = Conceptual core of the nurses’ influence on hospital’s performance ratings under CMS’s incentive-based programs

Value-Based Purchasing (VBP) Program Incentive-based payments Hospital VBP Performance Score: Process of care, Patient Experience of Care, Outcome and Safety, Efficiency and Cost Reduction

Process of Care Domain FY 2014 FY 2015 FY 2016 FY* 2017 FY* 2018 Domain Weight 45% 20% 10% 10%    AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival X AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival IMM-2 Influenza Immunization HF-1 Discharge Instructions PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Perinatal Care: Elective Delivery < 39 completed weeks of gestation X*

Patient Experience of Care Domain FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 Domain Weight 30% 25%   Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 8 dimensions: Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication About Medicines Cleanliness and Quietness of Hospital Environment Discharge Information Overall Rating of Hospital X 3-Item Care Transition Measure Patient/family preferences taken into account in post-discharge planning Patient had good understanding of self-management after leaving hospital Patient had clear understanding of medications after leaving hospital

Patient Outcomes and Safety Domain FY 2014 2015 2016 2017 2018 Domain Weight 25% 30% 40%   MORT-30-AMI Acute Myocardial Infarction (AMI) 30-Day Mortality Rate X MORT-30-HF Heart Failure (HF) 30-Day Mortality Rate MORT-30-PN Pneumonia (PN) 30-Day Mortality Rate PSI 90 Patient safety for selected indicators (composite) CLABSI Central Line-Associated Blood Stream Infection CAUTI Catheter-Associated Urinary Tract Infection SSI Surgical Site Infection (Colon, Abdominal Hysterectomy)

Efficiency and Cost Reduction Domain FY 2014 2015 2016 2017 2018 Domain Weight 0% 30% 25%   Medicare Spending per Beneficiary X

Relative VBP Domain Weights over Time

Hospital VBP Performance Score Points assigned for each measure depending on: How hospital performed on the outcome relative to benchmark How much hospital improved relative to benchmark in closing the performance gap Hospitals that have better outcomes OR improved more from baseline score higher (Source)

Financial implications Hospitals’ base operating DRG Medicare payments are reduced by 1.5% Performance score linearly transformed to incentive payment ranging from 0 to 2 x initial payment reduction (1.5%) Effective incentive range (-1.5% to +1.5%), or 3% FY2015: reduction - 1.5%, range - 3% FY2016: reduction - 1.75%, range - 3.5% FY2017: reduction - 2%, range - 4%

VBP Payment adjustments

Intersection of NDNQI and VBP Four NDNQI nurse-sensitive outcomes intersect with VBP-targeted outcomes: Central-Line Associated Blood Stream Infections (CLABSI) Catheter-Associated Urinary Tract Infections (CAUTI) Pressure Ulcer (PU) prevalence Ventilator-Associated Pneumonia (VAP)

CLABSI NDNQI VBP Program   CLABSI Central Line-Associated Blood Stream Infection Rates FY 2015: 6% (direct measure, Outcome and Patient Safety Domain) + 0.55% (indirect as part of PSI 90, Outcome and Patient Safety Domain) = 6.55% of total VBP Performance Score FY 2016: 5.71% (direct measure, Outcome and Patient Safety Domain) + 0.52% (indirect as part of PSI 90, Outcome and Patient Safety Domain) = 6.23% of total VBP Performance Score

CAUTI NDNQI VBP Program   CAUTI Catheter-Associated Urinary Tract Infection Rates FY 2015: 6% (direct measure, Outcome and Patient Safety Domain) of total VBP Performance Score FY 2016: 5.71% (direct measure, Outcome and Patient Safety Domain) of total VBP Performance Score

PU prevalence NDNQI VBP Program   Pressure Ulcer Incidence Rates from Electronic Health Records FY 2015: 0.55% (indirect as part of PSI 90, the Outcome and Patient Safety Domain) of total VBP Performance Score FY 2016: 0.52% (indirect as part of PSI 90, the Outcome and Patient Safety Domain) of total VBP Performance Score

VAP rate NDNQI indicator VBP Program   Ventilator-Associated Pneumonia Rates Related to the outcome measures of “30-day pneumonia mortality rate” (Outcome and Patient Safety Domain) accounting for 6% of total VBP Performance Score in FY 2015 and 5.71% of total VBP Performance Score in FY 2016

What outcomes should be targeted by nurses? CAUTI/ CLABSI together account for over 12% of the hospital’s performance score – primary focus PU prevalence, VAP are also important

Where are we now? HAC-prevention bundles => Up to 41% CLABSI 6-14% CAUTI Up to 40% VAP However, adoption and adherence are low: CLABSI 87-97% adoption, 37-71% adherence CAUTI 27-68% adoption, 6-27% adherence VAP 69-91% adoption, 45-55% adherence Improving adoption and adherence is key

What can we do to improve? Educating all physician and nursing staff on evidence-based practices Empowering nurses to ensure compliance with check lists Providing feedback on infection rates at the nursing unit level Shared ownership of infection rates between infection prevention specialists and nurses Physician and nurse champions to facilitate nurse interceptions of checklist breach (Source)

Importance of nursing structure staffing, skill mix, education => Improved outcomes of 30-day mortality, pressure ulcers, readmissions, lower costs of care work environment (collaboration between physicians and nurses, opportunities to participate in hospital- and unit-level decisions, and continuing education opportunities) Reduced mortality, readmissions, lower costs, lower failure to rescue

National Database of Nursing Quality Indicators (NDNQI) Conclusion National Database of Nursing Quality Indicators (NDNQI) Targeted by CMS Nursing- sensitive Outcomes Structure: staffing, skill mix, and education Improved nurse work environment Process: increased adoption/ adherence with HAC prevention bundles CLABSI CAUTI PU VAP

Formula for Success High-value provider of patient care = Focuses on outcomes-specific evidence-based nursing interventions + Invests in training and education of nurses + Committed to a positive nurse work environment