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

2. 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?

3. 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

4. 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

5. 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

6. 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*

7. 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

8. Patient Outcomes and Safety DomainFY
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)

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

10. Relative VBP Domain Weights over Time

11. 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)

12. 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 %, range - 3.5%
FY2017: reduction - 2%, range - 4%

13. VBP Payment adjustments

15. 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)

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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