Health Care Delivery Models and Nursing Practice NRS-440V

Health Care Delivery Models and Nursing Practice NRS-440V

Health Care Delivery Models and Nursing Practice NRS-440V

Assessment Description

The United States has the most complex healthcare system globally. The complexity has led to slow reforms due to policies, environmental and technological factors. Nevertheless, the system requires a change to meet current illness trends, technological shifts, and doctor demographics (Emanuel, 2018). The purpose of this paper is to describe a current healthcare law and its impact on nursing practice and nursing roles. The paper will also outline the effects of pay per performance and quality measures on patient outcome, professional nursing leadership and management roles that have emerged and emerging trends and how nursing roles and practice will change in response to the upcoming trends.

The Medicare Access and CHIP Reauthorization Act (MACRA)

In 2015, The Medicare Access and CHIP Reauthorization Act (MACRA) became law. The bill came up with a quality payment program that repealed the Sustainable Growth Rate Formula and introduced the value-based payment reforms (Sayeed et al., 2017). The bipartisan legislation ensured that clinicians were no longer rewarded for volume but rather for value. Through the Merit-Based Incentive Payments System (MIPS) multiple quality programs were streamlined and bonus payment included for providers who participated in eligible alternative payment models (APMs).  The bill proposes the removal of Social Security Numbers (SSNs) from Medicare cards to protect financial information, private health care, and federal health care benefits and service payments (Sayeed et al., 2017). The bill also aims at advancing quality measures that drive value in care, improve patient outcomes, and reduce the burden on clinicians. The bill will leverage the expertise and insight of the providers to build a truly value-based healthcare system.

MACRA Effects on Nursing Practice and Role

As part of Medicare providers and managed care professionals, nurses’ roles have been affected. MACRA affects how policy are developed, performance measures, reimbursements, care coordination and clinical-coding review. Nurses have to ensure that the MACRA principle of providing good care with the least cost and using HIT is met (Ma et al., 2018). MACRA makes providers more conscious of efficiency and outcomes which promotes care management styles. The act helps in reducing duplication of services, costs for individual, and unnecessary medical procedures. It addresses wasteful spending, the need for standard and available cost and outcomes data, and ineffective health interventions. The act fosters patient-centered care and thus enhances team-based care and the need to have clearly defined roles and responsibilities for team members (Ma et al., 2018). Responsive and respectful care is expected from nurses to meet individual patient values, needs and preferences. Equally al clinical decision should be based on patient values.

Pay For Performance (P4P), Quality Measures and Patient Outcomes

Pay for performance offers financial rewards or penalties depending on performance on measures of quality. P4P should, therefore, drive providers and health care systems to enhance the delivery of care, reduce expensive health care services, and enhance patient health outcomes. Patient outcomes should improve because providers will not rely on a high volume of services but will adopt procedure-based care (Mendelson et al., 2017). P4p reduce the cost of care and improve the patient experience. Research indicates that P4p improves initial hospital readmissions, boosts process-of-care performance, and has led to appropriate high blood pressure responses in the ambulatory settings. P4P follows the quality of measures and thus ensures that effective, efficient, equitable, safe, and timely care is provided.

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Effects on Nursing Practice

As indicated above, the P4P initiative aligns desired care processes and outcomes with reimbursement, driving the quality of care. Nurses have to understand the necessary processes and outcomes and gain the requisite knowledge to offer care competently. To improve patient outcomes, nurses require tools and resources, collaboration with other health workers, and the freedom to exercise judgment on behalf of patients (Kondo et al., 2016). Hospitals have to invest in nursing care by enhancing staffing levels and nurse education as a move to reduce adverse events. Reduction in adverse events will positively impact the P4P initiatives. The investment will ascertain high-quality nurse practice settings which will guide in performance and documentation of key treatments and evaluations. Nurses are also expected to diagnose problems with processes and implement solutions that meet the P4P indicators.

Emerging Roles

Nurse roles have changed to meet the emerging trends. The roles enable the nurses to autonomously diagnoses and treat illness, prescribe medication, perform procedures, and order and interpret tests. A new role is nurse informaticists to handle emerging technology, increase efficiency, and improve patient care outcomes (Sherman & Saifman, 2018). Another role is policymaking. The emergence of covid19 has also created new leadership roles like advanced practice nurses in community care settings to handle the projected primary care physician shortage ahead. APRNs have to function as primary care providers. A role like a telephone triage nursing in outpatient primary care has also emerged. The role is helping in establishing patients at risk of coronavirus. Nurse practitioners are also partnering with paramedics in homecare settings to prevent readmissions for hospitalized patients. The roles enhance patient safety because they are extending nurses’ focus on the patient journey along the care continuum (Sherman & Saifman, 2018). The roles are also helping in creating healthy work environments, analyzing information, and developing public health policies and programs.

Emerging Trends

Currently, there are demographic shifts and societal changes that are exerting pressure on health systems. The aging population is on the increase driving up the demand for healthcare. The world population is estimated to increase by one billion in 2025 (Coster et al., 2018). 300 million will consist of people above 65 years old creating a need for additional healthcare resources and service innovation to deliver long-term care and chronic disease management services. Another emerging trend in healthcare is consumerization. Patients can access the internet and learn about their conditions (Bautista et al., 2018). They come for appointments ready to discuss potential symptoms, diagnoses, and treatments.

Old age results in significant deterioration of physical and mental capacities. Nurses have to get additional education in geriatric care best practices to ensure that they can comfortably handle the increasing old age population (Coster et al., 2018). Additionally, the age population will cause an upsurge of chronic health conditions and therefore the next generation of nurses and nursing leaders have to work in long-term care and other geriatric nursing environments. Nurses may also benefit from pursuing doctorate degrees to get a better grip on geriatrics. Consumerization on the other hand is creating a patient-centric care approach. Nurses will be able to get a clear picture of patient needs and better manage their health. Patient involvement will also allow nurses to provide care beyond hospital walls. Consumerization will also allow nurses to utilize virtual health services and patient-generated data to monitor patients and ascertain that they have adequate information without visiting the office (Bautista et al., 2018). Consumerization will also enhance patient engagement and positively impact patient satisfaction scores a move that will support the current value-based care system.

References

Bautista, J. R., Rosenthal, S., Lin, T. T., & Theng, Y. L. (2018). Predictors and outcomes of nurses’ use of smartphones for work purposes. Computers in Human Behavior, 84, 360-374.

Coster, S., Watkins, M., & Norman, I. J. (2018). What is the impact of professional nursing on patients’ outcomes globally? An overview of research evidence. International journal of nursing studies, 78, 76-83.

Emanuel, E. J. (2018). The real cost of the US health care system. Jama, 319(10), 983-985.

Kondo, K. K., Damberg, C. L., Mendelson, A., Motu’apuaka, M., Freeman, M., O’Neil, M., … & Kansagara, D. (2016). Implementation processes and pay for performance in healthcare: a systematic review. Journal of general internal medicine, 31(1), 61-69.

Ma, Y., May, N., Knotts, C., & Dabbs, A. D. (2018). Opportunities for nurses to lead quality efforts under MACRA. Nursing Economics, 36(2), 97-101.

Mendelson, A., Kondo, K., Damberg, C., Low, A., Motúapuaka, M., Freeman, M., … & Kansagara, D. (2017). The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review. Annals of Internal Medicine, 166(5), 341-353.

Sayeed, Z., El-Othmani, M., Shaffer, W. O., & Saleh, K. J. (2017). The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: what’s new?. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 25(6), e121-e130.

Sherman, R. O., & Saifman, H. (2018). Transitioning emerging leaders into nurse leader roles. JONA: The Journal of Nursing Administration, 48(7/8), 355-357.

 

The need to deliver quality and affordable care implores stakeholders to continually enact legislations to reform and restructure the health care delivery system with the aim of attaining better outcomes. Nurses are critical players in these reforms and restructuring since they are patient advocates. The new delivery models emerge to offer quality care at the greatest value for patients and stakeholders like nurses (Gott, 2018). The purpose of this paper is to examine changes aimed at reforming or restructuring health care delivery system through a current law or federal regulations. The paper also discusses effect of quality measures and pay for performance in patient outcomes and nursing practice. The essay also discusses professional nursing leadership and management roles in response to emerging trends and in patient safety and quality care promotion.

Current or Emerging Health Care Law or Federal Regulation

The need to improve nursing education and practice is critical to care provision in the U.S. health care system. Imperatively, the Nursing Workforce Reauthorization Act 0f 2019 is essential as it would update, reauthorize and enhance critical programs to help grow and support the nursing workforce as one of the largest labor force in the country. The Nursing Workforce Reauthorization Act of 2019 focuses on enhancing nursing education, practice and programs to retain nurses to meet the growing national demand due to an aging population and subsequent retirement of baby boomers’ nursing generation (Merkley, 2019). The law offers many programs to nurse practitioners to enhance nursing care, services and improve the overall wellbeing of these practitioners. The focus of this act is to provide more accountability to the nurse and improve scope of practice to allow increased satisfaction in the profession and lead to better retention rates.

The act will assist in aligning the nursing field within its profession as nurse get opportunity to advance their education and serve in both rural and urban areas, especially among underserved populations and communities. The act ensures that nurses will have increased skills to practice based on their level of education, training, and specialty. The act implores nurses to be more accountable in their role as primary care providers, especially in rural and underserved communities (Congress.GOV., 2019). The act ensures that the American nursing workforce is well positioned to meet care need now and in the future and can address access to care challenges in the populations where they serve.

Quality Measures/ Pay for Performance

Economic changes are essential for health care delivery in the country to remain sustainable while offering quality patient care. The Centers for Medicare and Medicaid Services (CMS) develops measures to lower the cost of care and increase access. Pay for Performance is a component of quality measures aimed at rewarding healthcare entities and providers that focus on quality care and enhancing patient outcomes. Pay for performance stresses the important of quality of care and not quantity which increases the possibility of using best clinical practices and supports promotion of good health. Pay for performance increases transparency while encouraging providers to remain accountable and enhance their overall reputation.

Using data on quality measures established in collaboration with the Agency for Healthcare Research and Quality (AHRQ), organizations and providers get financial rewards for enhancing patient care and reducing costs. Through the intervention, CMS can hold organizations and providers accountable for their shortcomings. The pay for performance is a value-based model and uses patient satisfaction and proven best practices as quality measures. Hospitals and providers report quality metrics to the public using the Hospital Consumers Assessment of Health Plan Survey (HCAHPS), and quality measures associated with falls, infections, morbidity, and mortality in different patient settings (Lee & Nathan, 2018). Providers and organizations use the Healthcare Effectiveness Data and information Set (HEDIS) for reporting these measures in outpatient settings.

Nurses, including advanced practice registered nurses (APRNs), leaders and administrators have direct influence on quality programs and patient outcomes. Nurses should know and understand the current concepts on quality that include a selection of quality measure, data collection and measurement, data reporting and effective evaluation (Gott, 2018). Nurses need to be aware of and understand as well as promoted their roles and the impact they have on high quality patient care and outcomes. They need to advocate for resources, foster a safety culture, participate in policy and decision making concerning best practices and lead in the implementation of quality initiatives.

Leadership and Management Roles and Emerging Trends

The nursing profession is in a strategic position in the health care reforms and transition taking place and development of effective patient care models. The advent of these novel care models that aim at preventive measures and health promotion across have led to emergence of new roles among nurses and other healthcare providers. These novel positions and managerial roles include being care coordinators, primary care providers, virtual care nurses, bundled care coordinators and working in retail clinics, especially in health care deserts in rural settings (Sarkar et al., 2020). All these roles are essential since patient care continues to become complex and extending beyond the confines of healthcare settings.

Nurses are becoming primary care providers and leading the provision of care in rural settings and among different patient populations, especially vulnerable populations and communities. As health care coaches and patient advocates, they help patients set wellness goals, especially those with chronic conditions. New roles like being patient navigators ensures that patients go through their complex care journeys with increased hope and better advice from nurse practitioners (Lee & Nathan, 2018). As such, nurse leaders and managers must be visionary and use evidence-based practice interventions to enhance care delivery a. The emerging act implores nurse managers to understand the financial implications of healthcare and care for communities in a more cost-effective manner than before.

Emerging Trends in Technology and Holistic Care

Different trends will continue to define healthcare provision and care plans in the healthcare system. Among these trends include the shift to nurses as primary care providers due to a decline in primary and specialty care physician, emerging technology’s increased use, and focus on holistic care interventions. The shift to APRNs and RNs is due to the need to maintain public health coverage and increase access, especially as states continue to change laws and increase the scope of practice authority for nurses. Emerging technology will continue to define, design, and shape care provision as more patients become reliant on telehealth and telemedicine through virtual nurses and physicians (Gott, 2018). The emergence of infectious diseases and the need for increased disease surveillance and control of such spread underscore the need for better preparation among health care providers, especially nurses.

Another trend is the emergence and development of Patient Centered Medical Homes (PCMH) as part of offering better access to holistic care. many of these settings are managed and staffed by advanced practice registered nurses (APRNs) and registered nurses (RNs) (Sasangohar et al., 2018). These trends imply that there will continue to be a shift in the entry level into nursing with more institutions requiring baccalaureate level to be hired by hospitals and the medical homes. The use of telehealth and telemedicine applications will imply that more nurses will specialize in nursing informatics.

Conclusion

Nurses are positioned strategically to transition patient care through advocacy, advanced education, training, policy making and leadership. Nurses must keep pace with emerging delivery models to offer safe, effective, and quality care for all patients and ensure that they get the best value outcomes. Nurses should understand the emerging trends and seek effective ways to prepare strategically as critical players in the current reforms.

References

Congress.GOV. (2019). H.R.728 – Title VIII Nursing Workforce Reauthorization Act of 2019.

https://www.congress.gov/bill/116th-congress/house-bill/728/actions

Gott, M. (2018). Telematics for health: The role of telehealth and telemedicine in homes and

            communities. CRC Press.

Lee, J. S., & Nathan, H. (2018). Quality measurement and pay for performance. Surgical

            Oncology Clinics, 27(4), 621-632. doi: 10.1016/j.soc.2018.05.003.

Merkley, J. (2019). Merkley, Burr Introduce Bipartisan Nursing Workforce Reauthorization Act

of 2019. https://www.merkley.senate.gov/news/press-releases/merkley-burr-introduce-bipartisan-nursing-workforce-reauthorization-act-of-2019

Sasangohar, F., Davis, E., Kash, B. A., & Shah, S. R. (2018). Remote patient monitoring and

telemedicine in neonatal and pediatric settings: Scoping literature review. Journal of medical Internet research, 20(12), e295. doi: 10.2196/jmir.9403

Sarkar, R. R., Courtney, P. T., Bachand, K., Sheridan, P. E., Riviere, P. J., Guss, Z. D., … &

Murphy, J. D. (2020). Quality of care at safety‐net hospitals and the impact on pay‐for‐performance reimbursement. Cancer, 126(20), 4584-4592. https://doi.org/10.1002/cncr.33137

 

Health outcomes typically depend on health care delivery models and population-based interventions for healthy living. Progressively, as situations necessitate, massive changes have been introduced to reform or restructure the U.S. health care delivery system to ensure better services to individuals and communities. These reforms have prompted many changes in the practice environment hence the need for nurses to understand current and possible developments in the future. Their roles in the changing environments will also be changing as reform occurs. The purpose of this paper is to examine changes introduced to reform health care delivery and the nurse’s role in the changing environment.

Current Health Care Regulation for Reforming Health Care Delivery

Federal regulations have been instrumental in health care reform to ensure people get accessible and affordable care. When the COVID-19 pandemic broke out, access to care was hampered as the government provided many directives for reducing transmission, including restricting movement and physical interaction. Since people still required health care services for other illnesses amid the pandemic, the US Centers for Medicare & Medicaid Services (CMS) authorized waivers to expand telehealth services for Medicare beneficiaries. Approved in March 2020, these waivers allowed more use of telehealth services, including in-home visits and care services in urban areas (Suran, 2022). The CMS further allowed audio-only interaction via telehealth for some health care services.

Health care reforms have significant effects on nursing practice. According to Suran (2022), the waivers by the CMS in 2020 intensified the use of telehealth services, implying an increased demand for remote health care services. In response to the increased demand for remote care, health care organizations should implement the appropriate technological infrastructure to support telehealth and related technology-related services. As Ford et al. (2020) suggested, a robust technology infrastructure is crucial to prevent risks associated with telehealth in patient care, primarily security and privacy breaches. As these developments occur, health care organizations should also expect more demand for remote health care services hence the need to adjust their delivery models to accommodate appropriate changes.

The nurse’s role and responsibility include appropriate adaptation, supporting technology-driven practice, and promoting a culture of change in the workplace. According to Triana et al. (2020), telehealth use is hampered by negative attitudes, particularly among providers without the appropriate technological skills to implement it safely and effectively. To reduce possible risks, nurses should embrace teamwork when offering tech-based services. A culture change is necessary to ensure that nursing teams are more open to change and can readily embrace new technologies to support patient care. Importantly, nurses should encourage and support patients to embrace telehealth for higher outcomes.

Quality Measures and Pay-for-Performance

Quality measures include processes and outcomes for assessing whether health care services achieve the desired outcomes. As a result, health care professionals use quality measures to assess performance and make decisions that increase the probability of achieving the desired outcomes (CMS.gov, 2021). On this premise, quality measures are a foundation of high-quality care since they guide nurses in improving outcomes. Pay-for-performance (P4P) encourages value-based care. In P4P schemes, health care providers are incentivized based on how they meet predefined targets for quality care (Kyeremanteng et al., 2019). Consequently, providers intensify measures for positive patient outcomes to get maximum incentives.

Quality measures and P4P promote high care quality, which is a core objective of the nursing practice. As their role stipulates, nurses should always be committed to delivering comprehensive care. Accordingly, they should focus on value, efficiency, and quality, among other elements that define satisfactory care (Kyeremanteng et al., 2019). Nurses should expect more pressure from stakeholders and patients to provide a higher value as time advances. Their primary role is to use quality measures as the reference for continuous quality improvement. Nurses should also promote P4P by increasing value through practices that reduce adverse events and allow them to use health care resources efficiently.

Professional Nursing Leadership and Management Roles

The scope of nursing practice and professional roles changes gradually. In nursing leadership and management, health care leaders and managers are currently obligated to lead change in practice settings. This role typifies serving as change agents where nurse leaders identify practice problems, develop appropriate interventions, and lead the implementation process. The other critical role for nurse leaders and managers in the evolving practice is knowledge work. The role of a knowledge worker is characterized by gathering information and interpreting it systematically for improved health outcomes (McGonigle & Mastrian, 2021). These roles are pivotal in effective responses to emerging trends since they improve leaders’ readiness and responsiveness to change. For instance, change agents promote a culture of change to ensure organizations have the appropriate climate and resources for supporting new practices. As knowledge workers, nurse leaders use their theoretical and analytical knowledge to identify health care patterns and respond appropriately. Since each role encourages quality improvement and practice change, there is a higher chance of improved patient safety and high-quality care after implementing innovative practices.

Emerging Trends and Nursing Transformation

Nursing is an evolutionary practice that evolves progressively to address current and emerging patient care demands. Concerning emerging trends, increased use of technologies, such as artificial intelligence and telehealth, a nursing shortage, and the adoption of value-based practice dominate nursing. In response, nursing practice and roles must transform to respond to the upcoming trends effectively. One of the possible ways that nursing will transform in the next five years is an increased inclination toward technology-driven and data-driven practices. Currently, data analytics allow health care professionals to identify trends to provide the most possible patient-centered care (Batko & Ślęzak, 2022). Over time, there will be more use of artificial intelligence and remote patient care to ensure people in rural and remote locations are diagnosed and treated timely and cost-effectively. The other potential transformation of nursing is a team-based practice in health care settings. Teamwork promotes interprofessional collaboration, which will allow nurse practitioners to achieve the goals of value-based care.

Conclusion

Health care delivery models affect how nurses work, practice goals, and care processes. Federal regulations and health care laws continue to influence care delivery models, and more changes are expected in the future. In the current practice, federal regulations through the CMS have allowed more use of telehealth services by authorizing waivers. As technology evolves, nursing practice is expected to be more data-driven and technology-centered. Effective adoption of tech-based services requires organizations to invest in robust technological infrastructure to support innovative practices.

 

 

References

Batko, K., & Ślęzak, A. (2022). The use of big data analytics in healthcare. Journal of Big Data, 9(1), 3. https://doi.org/10.1186/s40537-021-00553-4

CMS.gov. (2021). Quality measurement and quality improvement. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-#:~:text=Patient%20and%20families%20use%20quality,likelihood%20of%20desired%20health%20outcomes.

Ford, D., Harvey, J. B., McElligott, J., King, K., Simpson, K. N., Valenta, S., … & Lenert, L. A. (2020). Leveraging health system telehealth and informatics infrastructure to create a continuum of services for COVID-19 screening, testing, and treatment. Journal of the American Medical Informatics Association, 27(12), 1871-1877. https://doi.org/10.1093/jamia/ocaa157

Kyeremanteng, K., Robidoux, R., D’Egidio, G., Fernando, S. M., & Neilipovitz, D. (2019). An analysis of pay-for-performance schemes and their potential impacts on health systems and outcomes for patients. Critical Care Research and Practice, 2019, 8943972. https://doi.org/10.1155/2019/8943972

McGonigle, D., & Mastrian, K. (2021). Nursing informatics and the foundation of knowledge. Jones & Bartlett Learning.

Suran, M. (2022). Increased use of Medicare telehealth during the pandemic. JAMA, 327(4), 313-313. doi:10.1001/jama.2021.23332

Triana, A. J., Gusdorf, R. E., Shah, K. P., & Horst, S. N. (2020). Technology literacy as a barrier to telehealth during COVID-19. Telemedicine Journal and E-health : the Official Journal of the American Telemedicine Association, 26(9), 1118–1119. https://doi.org/10.1089/tmj.2020.0155