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The importance of team-based care and care coordination in transforming the U.S. health care system into one that is value-based, achieves preferred outcomes, and focuses on improving health and quality of care. The document emphasizes the role of nurses in leading change, utilizing data and health technology, and working in interprofessional teams to provide high-quality, cost-effective care.
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The views expressed in this document are solely those of the National Advisory Council on Nurse Education and Practice and do not necessarily represent the views of the U.S. Government.
Marsha Howell Adams, Ph.D., RN, CNE, ANEF, FAAN Dean and Professor College of Nursing The University of Alabama in Huntsville Huntsville, Alabama
Maryann Alexander, Ph.D., RN, FAAN Chief Officer, Nursing Regulation National Council of State Boards of Nursing Editor-in-Chief, Journal of Nursing Regulation Chicago, Illinois
Cynthia Bienemy, Ph.D., RN Director Louisiana Center for Nursing Louisiana State Board of Nursing Baton Rouge, Louisiana End Date: 4/13/
Mary Brucker, Ph.D., CNM, FACNM, FAAN Assistant Professor School of Nursing Georgetown University Editor, Nursing for Women’s Health Arlington, Texas
Ann H. Cary, Ph.D., MPH, RN, FNAP, FAAN Chair, Board of Directors American Association of Colleges of Nursing Dean and Professor School of Nursing and Health Studies University of Missouri – Kansas City Kansas City, Missouri
John Cech, Ph.D. President Carroll College Great Falls, Montana Term End Date: 3/31/
Mary Ann Christopher, MSN, RN, FAAN Vice President of Community Health Horizon Blue Cross Blue Shield of New Jersey Newark, New Jersey
Tammi Damas, Ph.D., MBA, WHNP-BC, RN Director of Education and Academic Affairs Office of the Provost Georgetown University Washington, DC
Mary Anne Hilliard, Esq., BSN, CPHRM Executive Vice President, Chief Legal Officer Children’s National Health System Washington, DC
Ronda Hughes, Ph.D., MHS, RN, CLNC, FAAN Associate Professor Director Center for Nursing Leadership College of Nursing University of South Carolina Columbia, South Carolina
Christopher P. Hulin, DNP, MBA, CRNA President Middle Tennessee School of Anesthesia Madison, Tennessee
Linda Kim, PhD, MSN, RN, PHN Research Nurse Scientist Cedars-Sinai Medical Center Los Angeles, CA
Maryjoan Ladden, Ph.D., RN, FAAN Senior Program Officer Robert Wood Johnson Foundation Princeton, New Jersey
Lorina Marshall-Blake, MGA, FAAN President Independence Blue Cross Foundation Philadelphia, Pennsylvania
Donna Meyer, MSN, RN, ANEF, FAADN Chief Executive Officer Organization for Associate Degree Nursing San Diego, California
Teri Murray, Ph.D., APHN-BC, RN, FAAN Dean and Professor Saint Louis University School of Nursing St. Louis, Missouri
COL Bruce Schoneboom, Ph.D., MHS, CRNA, FAAN Associate Dean for Practice, Innovation and Leadership The Johns Hopkins University School of Nursing Baltimore, Maryland
Roy Simpson, DNP, RN, DPNAP, FAAN, FACMI Assistant Dean, Technology Management Professor Nell Hodgson Woodruff School of Nursing Emory University Atlanta, Georgia
NACNEP Chair CAPT Sophia Russell, DM, MBA, RN, NE-BC Director Division of Nursing and Public Health Bureau of Health Workforce Health Resources and Services Administration Rockville, Maryland
Designated Federal Officer Tracy L. Gray, MBA, MS, RN Chief, Advanced Nursing Education Branch Division of Nursing and Public Health Bureau of Health Workforce Health Resources and Services Administration Rockville, Maryland
Raymond J. Bingham, MSN, RN Writer/Editor Division of Nursing and Public Health Bureau of Health Workforce Health Resources and Services Administration Rockville, Maryland
population health outcomes (e.g., case management, care coordination, utilization management, team-based care, and understanding of health care finance) and how they impact value-based care.
Recommendation 4 : HHS should advance value-based care through funding of educational and training initiatives in the areas of population health, data analytics, informatics, and connected care (e.g., telehealth) to address the needs of rural and underserved communities.
In 2018, Alex M. Azar II, the Secretary of the U.S. Department of Health and Human Services (HHS), identified one of the HHS priorities as transforming the health care system to value- based care. On a national level, health care is a major federal expense. For patients and their families, health care costs can have a devastating, and often unpredictable, impact. According to HHS (2018), “Americans deserve better, cheaper health care. HHS is working to transform our system from one that pays for procedures and sickness to one that pays for outcomes and health.”
There are over 4 million registered nurses (RNs) in the United States, making nursing the largest of the health professions (NCSBN, 2019). Nurses work and lead in all areas of health care, from intensive care units in acute care hospitals to school health rooms, community clinics, and home care. In many rural or remote areas, and among other underserved populations, advanced practice registered nurses (APRNs) – those nurses with post-graduate training in many primary and specialty care areas – are often the only providers. Any changes to the operation of the health care system will have far-ranging implications as to how nurses learn, train, and practice; where they work; and how they are reimbursed for their services. Given its size and the many roles the nursing profession plays, it has the opportunity to assume a leadership position in the value-based transformation of health care.
While the term value-based care (VBC) has long been in the discussion on ways to improve health care, there are no clear and accepted definitions of, or measures for, what VBC means. According to Pendleton (2018), there has been little progress in the movement toward VBC because the many stakeholders, such as hospitals, providers, insurers, employers, policymakers, and patients, have no common ground for defining value and do not agree on what elements indicate value. Is value in health care best indicated by costs? By accessibility? By quality? By patient and family satisfaction with services? By outcomes? Value encompasses all of these components.
Many health professional organizations have offered definitions of VBC. The Center for Value- Based Medicine, formerly at Pennsylvania State University, has defined value-based medicine as “the practice of medicine incorporating the highest level of evidence-based data with the patient- perceived value conferred by health care interventions for the resources expended” (Bai, 2015).
A definition from the New England Journal of Medicine Catalyst (2017) states, “Value-based health care is a health care delivery model in which providers…are paid based on patient health outcomes. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way.”
The HHS Centers for Medicare & Medicaid Services (CMS) states that the current health care system pays providers based on the number of patients seen and services provided, without regard to patient outcomes. However, “the good work that clinicians do is not limited to conducting tests or writing prescriptions, but also taking the time to have a conversation with a patient about test results, being available to a patient through telehealth or expanded hours, coordinating medicine and treatments to avoid confusion or errors, and developing care
Team-based care has long been the subject of research, education, practice, and policy. Understanding team care and what it contributes to improved patient care, safety, and value- based outcomes is essential for the redesign of health care delivery, organizational quality, and provider and patient satisfaction. Nurses can take the lead in creating, coordinating, executing, and evaluating team-based care, especially in their unique practice of care coordination within VBC.
Recent seminal work from federal government and other organizations has identified a need to shift health care delivery from the volume of care (the number of patient visits, tests, procedures, etc.) to the value of the care delivered. To be successful, this shift demands a deep understanding by providers, educators, organizations, and policymakers of barriers and facilitators to VBC. The World Health Organization (WHO, 2010) stated that team-based care in interprofessional practice occurs “when multiple health workers from different professional backgrounds provide comprehensive health services by working with patients, families, care providers, and communities to deliver the highest quality of care.”
Over the last decade, many national reports have included a call to action to promote team-based care, education, and practice among all health professions. In a 2015 report on the impact of interprofessional education on performance in practice, the Institute of Medicine (IOM) (now the National Academy of Medicine) identified the need to continue to build evidence for teamwork on patient, populations, and delivery efficiencies and effectiveness. In assessing progress since its 2011 report, The Future of Nursing Report , the IOM found gaps in the evidence for improvements based on team-based practices and in work environments that reinforced team- based care delivery.
Two previous NACNEP reports addressed the need to promote interprofessional team capacity in nursing education and practice (HRSA, 2015); and the need to develop nurses who can deliver team-based care for effective population health care and management delivery (HRSA, 2016). In addition, the Josiah Macy Jr. Foundation (2016) recommends that nurses working in primary care be prepared to work in team-based care structures and that health care systems need to be transformed from individual practitioner to team-based care models. Furthermore, nursing curricula need to incorporate opportunities to develop teamwork knowledge and behaviors and to include patients and families in care processes.
A meta-analysis (McEwan et al., 2017) found that team training could be effective in improving both newly formed teams and intact teams. The pedagogic strategies of workshops, simulation- based teamwork training, and team debriefs/reflections were shown to significantly improve knowledge, attitude, and behaviors of trainees, compared to didactic methods alone. Passive learning alone appears to be neither sufficient nor effective to improve teamwork. Teamwork training that includes experiential activities, active learning, practice, and continued reinforcement and professional development in practice settings improves teamwork performance.
The modified and expanded Kirkpatrick model (Reeves et al., 2016) of learner outcomes has been explained by Brandt (2018) to include the discovery of teamwork education and capacity building, which can provide levels of learning and competencies during both nurses’ pre- licensure and continuing professional development. These include:
When examining the impact of team education and practice in health care delivery, the effectiveness of team performance is influenced by the individuals or groups constituting the teams, as well as other workplace factors. Braithwaite et al. (2016) found that professional tribalism, stereotyping, and hierarchies (personal characteristics of engagement) operate in clinical environments where structural and organizational cultures reinforce professional silos and hierarchical power in situ. However, when taken out of the clinical environment for education and training sessions, these providers did not display the same tribal characteristics for a variety of tasks and team-based conditions. The results suggests that team-based capacity- building interventions should focus on the workplace culture in an organization, which will reinforce the desired team-based delivery and de-incentivize professional tribalism. The findings by Braithwaite et al. may explain why newly graduated team-based and interprofessionally educated providers, including nurses, can become dissatisfied on the job when confronted with employer organizational factors that form barriers to effective team-based practice.
A 2015 IOM report found an alarming prevalence of errors in the U.S. health care industry that impact patient morbidity and mortality, despite widespread improvements in medical and nursing science, electronic health records (EHRs), health information systems and health care technology, and patient information awareness. As a result, the IOM called for more effective teamwork among providers, patients, and families to improve health care effectiveness and patient safety.
Exemplars abound in value-based health care delivery systems indicating the importance of teamwork in improving care. In these teams, nurses often lead the effort as they connect community and clinical partners to share relevant patient information, make referrals, and improve patient education resulting in better patient self-management of chronic conditions.
One such exemplar is the Accountable Community of Health team model lead and reported by Allard (2018) in Southwestern Vermont as they readied for valued-based reimbursement. The Accountable Community of Health model demonstrates improved outcomes from reorganizing to value-based health care delivery. By involving multiple sectors and teams in the community, this nurse-led model has been shown to decrease health care redundancy and shift acute care resources across communities as part of an integrated delivery model (AAN, 2018). The model incorporates efforts of transitional care registered nurses (RNs) with clinical pharmacists, social
and transition plans as one of the seven “Essential Intervention Categories” for avoidable complications and readmissions. Safety and quality improvements are desirable outcomes for team-based care. However, URAC (2018) reported that, “getting physicians and all other members of the patient’s care team to clearly and effectively communicate what they did, why they did it, and what needs to follow is very challenging.”
Conclusion
Moving from fee-for-service to value-based health care requires a paradigm shift in provider and organizational behaviors, processes, culture, and infrastructure. The opportunity to amplify the impact of care coordination through the use of teams will clearly reveal the advantage of VBC. All health care providers are on a journey together to improve the health of individuals, communities, and society.
Team-based care, which uses the full extent of licensing authority for practice and appropriate delegation and exchange of tasks to team members, is a key component of success for quality and safety. Team-based care offers expanded access to care as well as more effective and efficient delivery of services essential to high-quality care such as patient education, behavioral health care, self-management support, and care coordination. Team-based care also supports the job satisfaction of team members. Efficiency and effectiveness for improved quality, patient safety, population health, patient satisfaction, provider satisfaction, and appropriate cost containment are essential goals of teams in meeting the requirements of value-based care. A culture of care and ethos of the health professions team start with effective pre-professional education in team-based care using appropriate evidence-based pedagogy. This foundation must be reinforced through repeated clinical care team experiences, an organizational culture that demands a team approach, life-long professional development for all team members, and research that informs science, policy, and practice for sustainability.
As stated above, VBC encompasses a reimbursement structure that focuses on the outcomes of the health care services provided, as opposed to the fee-for-service model that renders payment regardless of care outcomes. VBC is based on the quality of the services provided, rather than the quantity of those services, with the intent that all health care providers perform at their highest level (RevCycleIntelligence, 2018).
However, different views on “value in health care” perpetuate the current health care model and impede a new transformative model of care whereby value is based on outcomes rather than output (Pendleton, 2018). Despite these discrepant views, most stakeholders agree that the current U.S. model and costs of health care is unsustainable. Data drawn from the 2014, 2015, and 2016 Commonwealth Fund International Health Policy Surveys show that the United States spent 17.2 percent of its Gross Domestic Product on health care, compared to other countries in the Organization for Economic Co-operation and Development, which spent an average of 9 percent (Schneider, Sarnak, Squires, Shah, & Doty, 2017). In terms of comparable outcomes, the U.S. ranked last on overall health care performance and near last on access, efficiency, equity and health care outcomes (Schneider, et al., 2017). Based on U.S. health care dollars spent relative to health outcomes, there is little doubt that efficiencies could be achieved with a
comparable level of service at less cost. Positive health care outcomes through cost-effective services should be the goal. However, this goal is difficult to achieve when some health care providers have limits and restrictions placed on their practice.
The basic RN license is obtained after the student completes a program of study at a school or college of nursing and then successfully passes the National Council Licensure Examination for Registered Nurses (NCLEX-RN). State legislators govern the authority that RNs can have and the services they can provide in any respective state and this authority is often referred to as the Scope of Practice (SOP).
One goal of VBC is to create a culture of health by emphasizing wellness, encouraging healthy lifestyles, and paying more attention to the social determinants of health, which include access to affordable and safe housing, healthy foods, exercise, and transportation. Nurses are vital to this culture change, as they are the largest segment of the health care workforce, spend the most time with patients, support family caregivers, and implement new models of care that can improve prevention, wellness, and population health outcomes.
RNs can take a leading role in the provision of VBC by practicing to the full extent of their licensure and education. Using their knowledge and expertise, the RN can play a pivotal role in value-based health care as the Care Coordinator. The American Nurses Association (ANA) defines care coordination as “a function that helps ensure that the patient’s needs and preferences are met over time with respect to health services and information sharing across people, functions, and sites” (ANA, 2012). RNs are key to reducing the fragmentation across multiple providers and entities, and serving as the conduit for communication among all members of the team, which includes the patient, the patient’s family, the health care provider(s), and others.
In 2017, the Tri-Council for Nursing (composed of four independent nursing organizations: the AACN, the ANA, the American Organization of Nurse Executives, and the National League for Nursing) published a joint statement addressing the role of the RN as the care coordinator in team-based care. As care coordinator, the RN is positioned to evaluate all aspects of care, including all interventions and services provided, resulting in positive patient outcomes, improved interprofessional practice, and a decrease in costs (Tri-Council for Nursing, 2017).
In addition to the licensure exam for the RN, APRNs take an additional examination for certification at the advanced level in one of four advanced practice roles: nurse practitioner (NP), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified registered nurse anesthetist (CRNA). The APRN’s SOP varies by state and can range from independent practice to collaborative practice or consultative arrangements with varying degrees of physician collaboration and oversight (Adams & Markowitz, 2018).
The 2011 IOM report, The Future of Nursing , funded by the Robert Wood Johnson Foundation, noted that allowing APRNs to practice to the full extent of their education and training (full SOP) could lessen the burden on the current primary care system, which currently lacks provider
As the nation continues to define what VBC will represent, there are several key components that can enable the potential transformation of our health care system, particularly involving nurses – the largest group of health professionals in the nation.
In a 2018 presentation, Dr. Patricia Brennan, the director of the National Library of Medicine, noted that the information substrate for health care delivery and decision-making is increasingly data focused. However, there is a wide range of data sources.
Electronic health records (EHRs) are a key component of health care information systems used by health care clinicians and systems. Following passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 (HITECH Act, 2009), and Meaningful Use requirements, the majority of hospitals have replaced paper-based documentation records with EHRs.
Through these initiatives, the federal government made a huge investment in the deployment of EHRs throughout the country. However, nursing documentation was often left only as a free- text section, and thus cannot be incorporated in a meaningful way in the patient record. As a result, nursing documentation cannot be extracted, and most EHRs neglect a very rich source of information that could enhance patient care. In addition, nurses at the bedside lack anything that defines their care in the EHR as separate and distinct. Thus, the outcomes of nursing care are difficult to track for hospitals and health organizations, as well as for health insurers. While the implementation of EHRs has made improvements in addressing concerns regarding the time needed to document and improve communication (Holyroyd-Leduc, Lorenzetti, Straus, Sykes, & Quan, 2011; Silow-Carroll, Edwards, & Rodin, 2012), several additional improvements are needed before the potential of EHRs can be fully realized.
In a recent study, more than half of the nurses working in informatics (also known as nurse informaticians) reported that EHRs have low usability for nursing practice (Topaz et al., 2016). These concerns are associated with data entry burden, how EHRs are designed, and a lack of EHR-enabled capabilities tailored for nursing, including decision support tools. Both regulatory and accreditation requirements have increased the documentation burden for nurses. The American Medical Informatics Association recommended that by 2020, EHRs should be simplified and modified to decrease the time required for documentation (Payne et al., 2015).
While EHR vendors market standardized software, health care organizations typically make and implement modifications to the initial design to customize certain features according to the perceived needs within the organization. When additional changes are needed, prioritization has not been inherently assigned to nursing, resulting in situations where paper-based records are considered more flexible and not at risk of technical glitches that impede workflow (Ward, Vartak, Schwichtenberg, & Wakefield, 2011). Future efforts are needed that focus on improving EHRs to enable and facilitate nursing practice, especially for nurses providing hospital-based care at the bedside, and to facilitate nursing documentation into workflow (Bakken et al., 2008).
If EHR capabilities for nursing are minimal or at the basic level, the practice of nurses is constrained. In a report by the Office of the National Coordinator for Health Information Technology (ONC), only one-third of EHRs implemented in non-federal acute care hospitals provided a comprehensive EHR functionality, including nursing orders and clinical decision support (CDS) (Charles, Gabriel & Searcy, 2015). It is important to increase access to enhanced capabilities, such as CDS, and more effective visual structuring of patient information (Topaz et al., 2016). With a base of over 4 million registered nurses (NCSBN, 2019), nursing needs greater representation within the ONC, which at the time of writing did not have a nurse at its executive table, in order to promote the usability of the EHR for all providers
Health information technologies, including EHRs and telehealth, and valued-based models of care can be successfully utilized to better prevent and manage chronic conditions by focusing on the strengths that each member of the care team can bring to patients. Focusing on wellness and higher value care means a greater emphasis on prevention-based patient services, with less need for expensive chronic disease management.
The proliferation of VBC models is changing the way that providers and organizations provide health care services. Emerging health care delivery models emphasize a team-oriented approach to patient care and sharing of patient data so that care is coordinated and outcomes can be measured easily. Two models, patient-centered medical homes and accountable care organizations, are leading this trend.
In value-based health care models, primary, specialty, and acute care services are integrated, often in a delivery model called a patient-centered medical home (PCMH). A medical home is a coordinated approach to patient care, led by a patient’s primary provider (physician or nurse practitioner) who directs a patient’s total clinical care team (Schottenfeld et al., 2016). To best meet a patient’s needs, PCMHs rely on the sharing of electronic health data among all providers on the coordinated care team. When important patient information is readily available for providers, such as results of tests and procedures performed by other clinicians, redundant care and associated costs can be reduced (Porter, Pabo, & Lee, 2013).
Accountable care organizations (ACOs) were originally designed by CMS and provide high- quality medical care to Medicare patients. Providers, hospitals, and other health care professionals work as a networked team to deliver, in a coordinated manner, the best possible care at the lowest possible cost. Each member of the team shares both risk and reward, with incentives to improve access to care, quality of care, and patient health outcomes while reducing costs. This approach differs from traditional fee-for-service health care, where individual providers are incentivized to order more tests and procedures and manage higher volumes of patients in order to get paid more, regardless of patient outcomes (McClellan, McKethan, Lewis, Roski, & Fisher, 2010).
In both PCMHs and ACOs, health information technology can: 1) enable the patient and providers to make care decisions together, 2) improve coordination and data sharing among team members and systems to help achieve patient population goals, and 3) assist the sharing of clinical and financial data with payers to demonstrate improvements in outcomes such as
NACNEP report and recommendations emphasize changes in policy and the allocation of resources to strengthen nursing’s ability to lead the transformation of the health care system to value-based care. The recommendations underscore the potential benefits to the nation of targeting Title VIII funding to support the essential development of the nursing profession and align nursing education and practice with new and emerging models of effective health care. These investments promise to advance nursing education and practice, and provide the necessary support for educational institutions and partners to devise new models of care to move the nation’s populace toward better health.
Recommendations
Recommendation 1 : The Secretary will promote value-based care through funding of demonstration projects that study cost, access, and quality outcomes of nurse-led interdisciplinary teams.
Recommendation 2 : The Secretary will promote value-based care through partnerships between community health centers and academia where APRNs have and do not have full practice authority, with the intent of collecting data showing the identified benefits and outcomes (patient, cost, access, quality).
Recommendation 3 : Congress should fund academic and practice initiatives that advance the development of undergraduate & graduate nurse competencies associated with improved population health outcomes (e.g., case management, care coordination, utilization management, team-based care, and understanding of health care finance) and how they impact value-based care.
Recommendation 4 : HHS should advance value-based care through funding of educational and training initiatives in the areas of population health, data analytics, informatics, and connected care (e.g., telehealth) to address the needs of rural and underserved communities.
AACN American Association of Colleges of Nursing
ACO Accountable Care Organization
ANA American Nurses Association
APRN Advanced Practice Registered Nurse
CDS Clinical Decision Support
CNM Certified Nurse-Midwife
CRNA Certified Registered Nurse Anesthetist
CNS Clinical Nurse Specialist
CMS Centers for Medicare & Medicaid Services
EHR Electronic Health Record
ER Emergency Room
HHS Department of Health and Human Services
HIPAA Health Insurance Portability and Accountability Act
HITECH Health Information Technology for Economic and Clinical Health
HRSA Health Resources and Services Administration
IPEC Interprofessional Education Collaborative
IOM Institute of Medicine (now the National Academy of Medicine (NAM))
NACNEP National Advisory Council on Nurse Education and Practice
NCLEX-RN National Council Licensure Examination for Registered Nurses
NP Nurse Practitioner
NPI National Provider Identifier
ONC Office of the National Coordinator for Health Information Technology
PCMH Patient-Centered Medical Home
RN Registered Nurse
SOP Scope of Practice
VBC Value-Based Care
WHO World Health Organization
