New Models of Care and Delivery Systems

will be integral to
accountable care organizations.
According to Shortell (2010):
The appeal of the ACO concept lies in its ability to
accommodate or respond to any of the new payment mechanisms full capitation, partial capitation, bundled or episode-of-care-based payment
and various add-on payments for coordinating care
or achieving defined quality and cost results (p. 17).
To enhance quality and cost effectiveness, an ACO
needs to be able to:
1. Care for patients across the continuum of care, in different institutional settings as well as the home
2. Plan, prospectively, for budgets and resource needs
3. Effectively use evidence-based protocols and comparative effectiveness research
4. Develop and support comprehensive, valid, and reliable measurement of performance (Devers &
Berenson, 2009)
Shortell (2010) goes on to describe other benefits
of ACOs:
ACOs create incentives for hospitals and physicians
to reduce unnecessary admissions through better
disease prevention and primary care; reduce preventable readmissions through better coordinated
care; and reduce unnecessary and costly use of hospital emergency rooms. The hospital business
model shifts from maximizing inpatient care margins to maximizing total care margins (p. 17).
So how do nurses contribute to cost-effective patient
care in the PCMH and ACO? A major focus in PPACA is
cost-effective care of patients with chronic illness, especially those with multiple co-morbidities. Certainly, advanced
practice nurses (APNs) will be a part of the health team in
these environments providing, based on their education
and certification, primary or specialty care to patients with
multiple chronic illnesses.
There are also major opportunities for ambulatory care
registered nurses (RNs) to provide and expand their work
with advocacy, education, and care coordination to these
populations using evidence-based practice protocols. Prior
fee-for-service payment mechanisms have incentivized
patients visits to the physician. In the PCMH, where the
patient is known to the entire health team, telephone/electronic mechanisms may be used to monitor and access
patients, triage patients to appropriate care sites and
providers, and teach or counsel patients in their homes. The
RN in ambulatory care will often be the initial telehealth
contact for patients. , the
ambulatory care RN can triage, educate, and counsel the
patient and often avoid an ambulatory visit or a visit to the
emergency room or readmission to the hospital. Telehealth
is commonly used in capitated care; it is a major cost saver
for the health care organization and a patient satisfier.
Health Reform Act:
New Models of Care and
Delivery Systems
Previous columns have discussed how the Patient
Protection and Affordable Care Act (PPACA), now a law,
focuses on health promotion and prevention and offers
opportunities for ambulatory care nurses to enhance services to patients and families. This months column will
focus on new delivery systems and models of care. PPACA
offers incentives to develop, test, and evaluate these new
delivery systems, and it is essential that ambulatory care
nurses be at the planning table.
It is also essential that the many major dimensions of
the ambulatory care nurse role, such as advocacy, care
coordination, education, quality improvement, and community outreach (Haas, Hackbarth, Kavanagh, & Vlasses,
1995) be built into these new delivery models, because
each of these dimensions demonstrates how the ambulatory care nurse is the touchstone for patients and families seeking and receiving care in ambulatory care settings.
PPACA is expected to decrease the cost of health care
over the next 10 years. The major ways that these cost savings will be accomplished are promoting health and preventing disease, decreasing reliance on fee for service, providing
cost-effective care, and using the electronic health record
(EHR) across settings. Two of the delivery systems highlighted in PPACA are the Patient Centered Medical Home
(PCMH) and the Accountable Care Organization (ACO).
PCMHs and ACOs
PPACA authorizes states to establish community-based
interdisciplinary or inter-professional teams to support primary care practices within a certain area. The Health
Teams discussed in PPACA may include nurses, nurse practitioners, primary care physicians, medical specialists, pharmacists, nutritionists, dietitians, social workers, and providers
of alternative medicine. The Health Team is expected to support patient-centered medical homes, which are defined as
models of care that include personal physicians, whole person orientation, coordinated and integrated care, and evidence-based medicine (, 2010).
Shortell (2010) asserts that in the PCMH physicians need to
develop strong reciprocal referral working relationships (p.
17) with specialty physicians and a local hospital. Essential
also to cost-effective care in the PCMH is use of integrated
electronic health records.
ACOs are organizational structures within which hospitals, physicians and others can work together to provide
the most cost-effective care and be held accountable
(Shortell, 2010, p. 17) for outcomes achieved. Presumably,
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12 ViewPoint MARCH/APRIL 2011
American Nurses Association. (2010). Health care reform tool kit.
Retrieved from
Devers, K., & Berenson, R.A. (2009). Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Timely analysis of immediate health policy issues.
Washington, DC: Urban Institute. Retrieved from
Haas, S.A., Hackbarth, D.P., Kavanagh, J.A., & Vlasses, F. (1995).
Dimensions of the staff nurse role in ambulatory care: Part IIComparison of role dimensions in four ambulatory settings.
Nursing Economic$, 13(3), 152-165.
Shortell, S. (2010). Delivery system reform: Accountable care organizations and patient-centered medical homes. In The Society for
Healthcare Strategy and Market Development (Ed.), Futurescan
2010: Healthcare trends and implications 2010-2015. Chicago,
IL: Health Administration Press.
Electronic Health Records
With an integrated EHR, patient information is readily
available and easily shared within the entire health team.
One of the reasons ambulatory care RNs must be at the
planning table when PCMHs and ACOs are being
designed, implemented, and evaluated is the need for EHR
documentation formats that reflect the work ambulatory
RNs are doing in areas of care coordination, monitoring,
counseling, and educating complex, chronically ill
patients. In the absence of readily available documentation
on care coordination done by the ambulatory care RN,
costly redundancies in care are likely within this patient
population. The EHR will be instrumental to integrated,
cost-effective care only to the extent that the entire health
team documents and can easily access the documentation
of the rest of the team. The EHR also means that test results
are available in a timely manner and duplication of testing
is avoided.
As health care administrators plan for PCMHs and
ACOs, it is critical that ambulatory RNs be involved in the
planning and design not only of their role in these new
delivery models, but also in the design of the health team;
health team communication (both in person and electronically); and valid and reliable evaluation tools and methods
to track the impact of new care delivery and outcomes
This column is an overview of PPACA initiatives.
Delivery system reform and new care delivery models
incentivized by PPACA will be presented and discussed in
more depth at the AAACN Annual Conference in April
2011. The conference presentations on new delivery models aim to illustrate the implications of these new models as
well as opportunities for ambulatory RNs to participate in
their development and be recognized as integral and valued for their essential contributions to cost-effective ambulatory care and patient and family care outcomes.
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of
Nursing, Loyola University of Chicago, Chicago, IL. She can be
reached at [email protected]
Access and Share Resources
in the Document Library
AAACN has started a new document library for members to share files with one another. Current resources
include position descriptions, our project management
tool kit, bibliographies, and new assets to help facilities on
the journey to achieve Magnet status. Many thanks to
Susan Paschke and her team for assembling the new
Magnet resources!
To access the document library, you must be logged in
to your member account at After logging
in, click on the link Document Library in the lefthand navigation bar. The main page of the library lists resource categories and how many files are in each one. By clicking on a
category, you will reach its document listing. From here,
you can read descriptions and download individual files.
Documents are stored primarily in Acrobat PDF or Microsoft
Word format, and icons next to each resource will indicate
the file type used.
We invite you to share your resources, as well! You can
find instructions for submitting a document in the library.
If your file doesnt match one of the categories that currently exist, simply let us know what the new category
label should be.
If you find the new document library helpful, let your
Board of Directors know. They are responsible for suggesting this great resource!
Rebekah Lazar is Manager, Internet Services, American Academy
of Ambulatory Care Nursing, Pitman, NJ. She can be reached at
[email protected]
Do you have questions about health care reform?
Would you like to share your ideas with others? Join us
on our Health Care Reform forum! AAACN members
are invited to express their opinions, ask questions, and
respond to other members to continue the
conversation about health care reform and how it will
affect ambulatory care nursing.
ViewPoint_MA11_Layout 1 3/3/11 10:50 AM Page 12
Copyright of AAACN Viewpoint is the property of American Academy of Ambulatory Care Nursing and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s
express written permission. However, users may print, download, or email articles for individual use.

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