Value-Based Purchasing An Opportunity for Clinical Nurse Leaders

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1 Value-Based Purchasing An Opportunity for Clinical Nurse Leaders Marjorie S. Wiggins, DNP, MBA, RN, FAAN, NEA-BC Senior Vice President, Patient Care Services/Chief Nursing Officer AACN-CNL Summit, Long Beach, CA January 14, 2016

2 Objectives Explain Value-Based Purchasing (VBP) - It s origin and the impact over the next several years Explain the opportunity for CNLs to have significant impact on cost and quality of care Provide one detailed example of how to improve a VBP outcome 2

3 By 2017, ~9% of Medicare payment is at risk 3

4 Value-Based Purchasing (VBP): What is it? In October 2012, Medicare began rewarding hospitals that provide high quality care the new Hospital VBP program. Hospitals paid under the inpatient prospective payment system are paid for inpatient acute care based on Quality of care not the VOLUME of services they provide. 4

5 It s not just a good idea; it s the law. VBP Required by ACA TITLE III IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE Subtitle A Transforming the Health Care Delivery System PART I LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM SEC HOSPITAL VALUE-BASED PURCHASING PROGRAM. ( (A) IN GENERAL. Subject to the succeeding provisions of this subsection, the Secretary shall establish a hospital value-based purchasing program (in this subsection referred to as the Program ) under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards under paragraph (3) for the performance period for such fiscal year (as established under paragraph (4)). The Fine Print: (7) FUNDING FOR VALUEBASEDINCENTIVE PAYMENTS. (A) AMOUNT. The total amount available for value based incentive payments under paragraph(6) for all hospitals for a fiscal year shall be equal to the total amount of reduced payments for all hospitals under subparagraph(b) for such fiscal year, as estimated by the Secretary. FISCAL YEAR % RED N

6 Health Care Quality: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ( I.O.M. 1990) Structure Measures Characteristics of physicians and health care facilities, e.g. specialty, board qualification, hospital ownership Process Measures Components of the encounter between a provider and a patient, e.g. tests ordered, procedures performed Outcome Measures Descriptors of subsequent health status, e.g. readmission, mortality Patient Experience Efficiency 6

7 The Measures The VBP Program has: FY2016: 24 measures FY2017: 21 measures Measures cannot be selected for the VBP until they have been posted on Hospital Compare for 1 year prior to the start of the VBP performance period. 7

8 Scores Each hospital may earn 2 scores on each measure: - 1 for Achievement, and - 1 for Improvement. The final score awarded to a hospital for each measure or dimension is the higher of these 2 scores. 8

9 Achievement Points During the performance period, Achievement Points are awarded by comparing an individual hospital s rates with the Threshold (median or 50 th percentile of all hospitals during the baseline period) and the Benchmark (mean of top decile or 95 th percentile during the baseline period) 9

10 Achievement Points Achievement Points Hospital Rate Awarded At or Above Benchmark 10 Below Achievement Threshold (50% percentile) 0 At or Above Achievement Threshold AND Below 1-9 Benchmark 10

11 Improvement Points Awarded by comparing a hospital s rates during the performance period to that same hospital s rates from the baseline period. Improvement Points Hospital Rate Awarded At or Above Benchmark 9 At or Below Baseline 0 Between Baseline period AND Benchmark

12 Consistency Points The Consistency Points relate only to the patient experience of care domain. The purpose of these points is to reward hospitals that have scores above the 50 th percentile in ALL 8 dimensions of the HCAHPS. If they do, hospital receives 20 points. If they DO NOT, the lowest dimension is compared to the range between the National 0 percentile (floor) and the 50 th percentile (threshold) and awarded points proportionately. This formula is used for each dimension. 12

13 Incentive Payment DRG payments to eligible hospitals will be withheld to provide the estimated $1.4 billion available for the program incentive. % FY Withheld FY % FY % FY % FY % FY % Succeeding Years 2.00% NOTE: The law requires CMS to redistribute the estimated $1.4 billion across all participating hospitals based on their performance scores. 13

14 Measures in these Domains in 2012 Determined VBP incentives for 2014: Stratus Health 14

15 Process Measures Give Way to Outcomes, Cost: Measures in these domains in 2013 determines VBP incentives for 2015: (2016: SSI 2017 MRSA, C Dif) Risk-adjusted and price-standardized payments for all Part A and Part B services provided from 3 days prior to a hospital admission (index admission) through 30 days after the hospital discharge Stratus Health 15

16 Emphasis on Outcomes Continues: Measures in these domains in 2014 determines VBP incentives for 2016: AMI7a Lytic within 30 of arrival PN6 Initial antibiotic selection for CAP immunocompetent SCIP2 Appropriate preop antibiotic SCIP3 Prophylactic antibiotic d/c ed within 24 (48) hours of surgery SCIP9 Urinary catheter removed po day 1 or 2 SCIP Card 2 Preadm BB and perioperative BB SCIP VTE2 VTE prophylaxis 24 hours before or after surgery l Stratus Health 16

17 Value Based Purchasing 2017 (Performance Year 2015) Stratus Health 17

18 Process Measures for VBP 2016 (Performance Year 2014) 18

19 OUTCOME Measures for VBP 2016: PSI 90 Composite (Performance Year 2014) 19

20 VBP Factor for 2015 (based on 2013 performance) (or about -$150,000) VBP Factor for 2014 = (or about $600,000) VBP Factor for 2016 = To Be Announced ~ early October 20

21 How do We Get From Here to There? A deep dive into ONE indicator 21

22 Outcomes Raising the Bar Raising the bar on outcomes is not an easy task. If it was, we would all be in the highest percent of care. It involves passion, energy, best practice, tenacity, patience, perseverance, acceptance of slow progress, no progress, and slipping back. It is never easy and it involves change in 22

23 23

24 Journey of Preventing 1 HAI The journey of preventing the occurrence of ONE Hospital Acquired Infection: CAUTI Catheter Associated Urinary Tract Infection 24

25 Cost of Nursing Sensitive Clinical Indicators CLABSI $8,187 to $32,756 CDC 2009 report adjusted for CAUTI $935 to $1,093 CDC 2009 report adjusted for PRESSURE ULCERS $20,900 to $151,700 Medicare estimated cost to hospital stay $48,500-adjusted 2013 Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay adjusted for Lawsuits: More than 17,000 lawsuits are related to pressure ulcers annually. It is the second most common claim after wrongful death and greater than falls or emotional distress. FALLS/Falls with Injury $6,927 to $35,126 AHRQ site referenced an article from 2011 but study data was from , adjusted for RESTRAINTS $363 to $450 Estimated to be per episode, depending on containment methods adjusted for CAUTI: $33,000-$55,000 University of Michigan CAUTI Calculator Courtesy of Sonja Orff, MS, RN, CNL, Clinical Nurse Leader, Maine Medical Center 25

26 The MMC 2012 Baseline: 131 Infections 43,134 Catheter Days The following is a limited list of the work that was done in this initiative over the course of 3+ years. 26

27 The Evidence 2012 First step was to get a handle on our existing policy: - Was it up to date with the latest evidence? - We reviewed IHI Best Practices, APIC, and CDC - We combed the literature for any new successful approaches that were evidence-based - We attended conferences and workshops to see what other people were doing. AACN-CNL Summit that year had a Vanguard winner that was successful in decreasing infections. Her approach: decrease catheter days. No Catheter = No CAUTI 27

28 Action 2013 CAUTI Committee formed: - Representatives from every unit (clinical nurse leaders and nursing assistants). - Rounded on every unit for 4 months to see if policy and protocol were being followed. Found inconsistent practice. - Clamped down on policy. Encouraged nurses to follow nursing protocol. - All the while reinforcing: Get the Catheter Out. No Catheter = No CAUTI 28

29 Data Collected data as to why patient was catheterized 29

30 Data Collection Tool 30

31 Equipment 2013 Bladder scanners ordered - Researched the literature on bladder retention - Worked with MDs not to catheterize patients with chronic retention. No Catheter = No CAUTI 31

32 Partnership Joanne Chapman, MSN, M.Ed., RN, NE-BC Director, Professional Practice Dr. Brian Jumper Pediatric Urologist Sonja Orff, MS, RN, CNL Clinical Nurse Leader 32

33 Dr. Jumper s Role Got MDs on board Talked with new Residents Called physicians who were not following protocol; convinced them to get catheters out 33

34 Educated ALL Staff Re-trained 1,500 nurses on catheter insertion using mannequin Educated ALL CNAs in catheter care 2 RNs for insertion one to do checklist 34

35 Equipment Surveyed all unit supply rooms Made sure all kits had closed systems Standardized to a 16 French smaller catheters cause less irritation Males over 50, used a Coude catheter 35

36 Daily Monitoring A person in the Nursing Office was assigned the task of reviewing all records of patients who had a catheter for appropriateness at 0700 Every floor called when catheter did not meet criteria and asked to remove Root Cause Analysis set up with every infection A full drill down performed every time 36

37 Doctor s Orders Ensured doctor s orders in place for every catheterization Went from 50% to 95% 37

38 Engaged Other Departments Had microbiology send daily culture and sensitivity reports Results directly to Nursing Office and reviewed every day 38

39 Results 39

40 Thank you! Questions/Comments? 40

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