Managing a staff shift from the long-held quantity-of-care model to the new quality-of-care model can be daunting and cumbersome, but it is a challenge that must be met for the progress of the healthcare industry. In a follow-up interview with MultiBriefs Exclusive (see Part I here), Cheri Bankston, RN, MSN, director of clinical advisory services for Curaspan, explains the ways hospital managers can help staff deal with the transition and "straddling the fence."

Meeting challenges

"The first step is to make sure your organization is aligned and prepared to meet the challenges of a shift to value-based episodes of care," Bankston said.

For example, managers shepherding this move to value-based care should "identify a champion to lead this initiative internally." Managers should also begin to develop subject-matter experts as well as possibly engage a third party to manage value-based programs.

"Success is dependent on managing this change across the continuum, and that means bringing together all providers of care outside the walls of the acute care stay — the admission desk to the staff nurse, to the home health agency and primary care physician," Bankston said. "There must be a basic understanding of value-based care and how it works. Staff and providers can usually get behind a program that will yield better patient outcomes at a lower cost to the patient."

Maintaining fee-for-service (FFS) billing while tracking and managing new value-based programs can be difficult. Mostly, as Bankston notes, it's difficult because the market hasn't fully shifted to a value-based system yet.

In fact, only a small percentage of programs are value-based at this time. According to the Centers for Medicare & Medicaid Service (CMS), the U.S. Department of Health and Human Services (HHS) seeks to have 85 percent of Medicare fee-for-service payments in value-based purchasing categories 2 through 4 by 2016, and 90 percent by 2018.

According to CMS, to help drive the healthcare system toward greater value-based purchasing, HHS has set a goal to have 30 percent of Medicare payments in alternative payment models (categories 3 and 4) by the end of 2016 and 50 percent in categories 3 and 4 by the end of 2018.

Achieving this will require an investment in alternative payment models such as accountable care organizations, advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for beneficiaries that are Medicare-Medicaid enrollees.

Post-acute care

Before the industry's transition to value-based care began, hospitals used data to determine length of stay (LOS) and cost per case as a way of increasing volumes on the most profitable diagnosis-related groups (DRGs) or revenue streams. But now the approach to care is entirely different.

According to Bankston, hospitals once focused primarily on which DRGs had the best margins and how could they increase volume for profit’s sake.

"There was little regard for outcomes or readmissions," she admitted.

Now hospitals are being asked to monitor patients after they are discharged from the hospital to create an ongoing evaluation of the patients' functional status: Do the patients get better or worse as a result of the treatment? Which PACs (post-acute care) have the best outcomes?

As Christopher Cheney points out in an article for HealthLeaders Media, this shift has had pretty visible effects: "With prodding from federal officials and an industrywide shift toward delivering services based on value rather than volume, healthcare providers are making progress on reducing hospital readmission rates, federal statistics show.

"From 2007 to 2011, the all-cause 30-day hospital readmission rate for Medicare fee-for-service beneficiaries held steady at about 19 to 19.5 percent, according to the Centers for Medicare and Medicaid Services. But those rates fell to 18.5 percent in 2012 and 17.5 percent in 2013, CMS reports."

Now healthcare managers have recognized that they have to work in tandem with all types of providers across the healthcare continuum for episodes of care, rather than what simply happens within the four walls of an acute-care setting that draws revenue.

"Healthcare and healthcare payments have historically been siloed," Bankston continued, but we are still a few years out from an easy way to get information across the continuum.

"That's why many progressive organizations are using experienced third-party vendors to manage patient populations across the entire episode of care, whether that's 30, 60 or 90 days the patient has to be managed in order to avoid readmissions and generate outcome needed," she said.

In his article, Cheney continued the thought, highlighting the thoughts of Mary Naylor, Ph.D., RN, a professor at the University of Pennsylvania School of Nursing, who said, "Healthcare providers have developed several strategies to reduce hospital readmission rates, but integrating these new strategies across organizations and demolishing the walls that have divided sectors of the healthcare industry for decades remain huge challenges.

"Transitional care will be effective if it is well integrated into a whole delivery system. It has to be connected. It can't be outside," Naylor continued. "What we absolutely don't want is someone leaving the hospital and no one follows up with them. We need to make the journey for patients much more seamless. Transitional care shouldn't be a standalone. It should be a standard way of delivering value for all high-risk populations."

Ensuring that staff have the proper management in place as well as the tools to make the shift from quantity of care to quality of care go smoothly, the proper preparation and awareness are necessary.

Therefore, hospitals and medical centers are responsible for making sure their staff understand that straddling the fence between the two worlds is no longer acceptable. Rather, patients' care experience should stretch beyond the hospital, ensuring they receive the short- and long-term care they need.