Hospital value–based purchasing: How acute care advanced practice nurses demonstrate value

Abstract

Hospital value–based purchasing (HVBP) is a budget neutral initiative from the Centers for Medicare & Medicaid Services designed to adjust the hospital payment system based on health care quality data. Hospital value–based purchasing is designed to promote improved clinical outcomes and better patient experience in the acute care setting. Advanced practice registered nurses (APRNs) in the acute care setting are instrumental to the success of health care institutions under the current payer model in the United States health care system. When APRNs use their advanced knowledge and leadership skills to champion quality improvement and patient experience projects, they may increase financial reimbursement within the HVBP system, thus demonstrating value to the health care institution. Four basic steps could help APRNs demonstrate value to the organization, understand the standard, evaluate your performance compared with the standard, identify opportunities, and implement projects or participate in projects. This article provides a broad overview of the HVBP structure and describes how APRNs can positively influence performance measures, thereby potentially increasing hospital reimbursement.

Introduction

Hospital value–based purchasing (HVBP) is a long-standing initiative from the Centers for Medicare & Medicaid Services (CMS) designed to adjust hospital payments based on health care quality data (Agarwal et al., 2020; CMS, 2017, 2019b; Fuller et al., 2019). The HVBP program remains a budget neutral effort because it uses a 2% withholding of reimbursement from select diagnosis-related groups (DRGs) to create a pool of money that is redistributed to hospitals based on a complex scoring system of performance within its domains (CMS, 2019a). Performance measures within these domains are authorized by Congress as part of the Affordable Care Act (CMS, 2020). Current domains include clinical outcomes, person and community engagement, safety, and efficiency and cost reduction.

The HVBP program affects payments for approximately 3,000 hospitals (CMS, 2020). Hospitals performing at the 50th percentile or better meet the performance threshold to begin receiving points. This means only hospitals performing as well as or better than 50% of all participating hospitals are eligible for points. Performance points are awarded based on performance compared with other hospitals or improvement from the hospital’s baseline in each of the four domains. This provides hospitals equal opportunity to obtain points from either high performance or improvement (Sacks et al., 2015; Zywiel et al., 2017). A high score could potentially result in an incentive payment greater than the original 2% withholding. A low score could result in payment of only the base operating DRG payment, thus a loss of the 2% withholding (Sacks et al., 2015; Zywiel et al., 2017).

Therefore, excellence is achieved by eliminating or reducing the number of adverse events, adopting best practices, and providing patient-centered care through coordination and process improvement. The need for health care services will continue to drastically expand as Americans participate in the affordable care act and the baby boomer generation increases enrollment in Medicare. This increasing demand for health care along with the push for higher quality of care is a beckoning of advanced practice registered nurses (APRNs) to evaluate the context of their nursing practice and identify competencies that will make APRNs the leaders to meet this plight. Although there are numerous APRN roles, the nurse practitioner (NP) and clinical nurse specialist (CNS) have a large presence in the acute care setting. Both roles have been part of the US health care industry for approximately 60 years. The purpose of this article was to provide a broad overview of the HVBP program structure and describe how APRNs can positively influence performance measures, thereby potentially increasing hospital reimbursement.

APRN value influence on the clinical outcomes domain

The clinical outcomes domain includes publicly reported patient level outcomes from specified DRG populations. These outcomes include 30-day mortality, 30-day readmission, excess days in acute care, 90-day complication post-elective joint surgery and are publicly reported on the Hospital Compare website (CMS, 2020). However, only 30-day mortality rates are included in the reimbursement scoring system. Therefore, APRNs should actively pursue and maintain specialty or national certification to validate their expertise and unique skill set. Additionally, this domain calls for APRNs to play an active role in formal and informal peer review processes such as morbidity and mortality meetings, post-event debriefings, and participate in councils focused on unit or population outcomes within their area of work. Such committee work exemplifies the ability of the APRN to identify barriers to best practice and contribute to the decision making of the interdisciplinary team. See Table 1 for domain measures and possible APRN strategies to influence this domain. Following are two published examples of APRN influence within this domain.

Table 1.

Clinical domain advanced practice registered nurse (APRN) strategies

Clinical Outcomes Domain

APRN Strategies

30-day mortality 30-day readmission Excess days in acute care 90-day complication post-elective joint surgery

Earn/maintain certification in the area of practice, if available Remain abreast of unit or department performance measures Collect data on person performance Monitor your own clinical practice and set individual performance goals Support or be involved in developing evidence informed standards and protocols Actively participate in patient focused councils Provide education to unit/department staff Lead a quality improvement project lead/participate in journal clubs Participate in the morbidity and mortality review process Use scientific inquiry to incorporate evidence into practice Engage in formal and individual peer review process

The role of the NP has often been benchmarked based on a physician medical management model. This provides an opportunity for the NP to affect the clinical outcomes domain within the HVBP program. This was previously demonstrated in a project reported by a neurocritical care team who initiated around the clock specialty coverage using an NP as the nocturnal care provider. Before implementing the nocturnist NP role, the overnight hours were covered by a general intensivist team and/or a neurology resident. The NPs providing overnight coverage were all certified in Emergency Neurological Life Support and received on-the-job training from the neuro-intensivist physician team. The NPs participated in a proactive rounding process and serial assessments of critically ill patients. After implementation, the team reported a 10% reduction in mortality in patients having aneurysmal subarachnoid hemorrhage. The NP influence on reducing mortality in this project supports their positive contribution to the Clinical Outcomes domain (Sacks et al., 2015; Zywiel et al., 2017).

The CNS role is frequently evaluated based on improvement in patient outcomes allowing the CNS to affect the clinical outcomes domain. For example, Mullennix et al. (2020) describe a project led by an emergency department CNS to reduce opioid overdose-related mortality. After completing a cost analysis, intranasal naloxone take-home kits were dispensed to at-risk patients. New clear concise standards of care and clinical practice guidelines along with patient education were developed. To implement this project, the CNS identified a feasible workflow and ensured adequate resources were available by collaborating with a multidisciplinary team. Staff education was provided with a peer-to-peer program. The project was implemented across 11 emergency departments, dispensing more than 250 naloxone kits. The project outcome reported a reduction in community residents’ mortality from 16.5 to 9.6 per 100,000. This success led to further system wide implementation that included inpatient units (Austin et al., 2020).

APRN value influence on the person and community engagement domain

The person and community engagement domain comprises patient responses to the Hospital Consumer Assessment of Health care Providers and Systems (HCAHPS) survey. From this survey, five dimensions are used for scoring: Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Communication about Medicines, Hospital Cleanliness and Quietness, Discharge Information, Care Transition, and Overall Hospital Rating. This domain summons the APRNs to be a proficient communicator within the interdisciplinary team and with patients and families. Additionally, when APRNs assume a leadership role in promoting and refining hospital processes, they improve patient outcomes and experience. In this, the APRN should monitor pertinent HCAHPS data as part of ongoing self-reflection on personal communication skills and effectiveness. Advanced practice registered nurses should use access to unit or service dashboards to regularly identify opportunities for improvement. By using their advanced knowledge and skills, APRNs must appraise appropriateness and effectiveness of tools and educational resources used in practice. Practicing active listening skills supports APRNs’ ability to provide culture-specific care to promote the best communication with patients and families. See Table 2 for domain measures and possible APRN strategies to influence this domain. Following are synopses examples of APRN influence within this domain.

Table 2.

Person and community domain advanced practice registered nurse (APRN) strategies

Person and Community HCAHPS Dimension

APRN Strategies

Communication with nurses Communication with doctors Responsiveness of hospital staff Communication about medicines Hospital cleanliness and quietness Discharge information Care transition Overall hospital rating

Collect data on your own clinical practice and set individual performance goals based on HCAHPS survey Self-reflect on personal communication skills and effectiveness Engage in enhancing hospital processes that improve patients’ experience of care Educate patients, their significant others, visitors, colleagues Ask patients/family to teach you how they will implement new plans of care Use rounding tools Communicate with cultural empathy and congruent of diversity Use language translation resources for effective communication

HCAHPS = Hospital Consumer Assessment of Health Care Providers and Systems.

There is a dearth of literature using conceptual frameworks to demonstrate the impact of the NP in acute care on the person and community engagement domain. Research has demonstrated the NP participation in hospital care results in improved connection with patients and families using communication on a level they understand (Jones et al., 2015). These findings were evident when a hospital implemented a NP-led interprofessional bedside rounding project. The project incorporated the use of structured rounding with a multidisciplinary team, patient, and/or family to review the plan of care, recent events, and progress. The NP-led rounding promoted effective team communication as well as patient and family engagement in the plan of care. This project resulted in improvement in HCAHPS scores including communication with the nurse increasing from 79% to 90% and provider communication from 69% to 85% (Austin et al., 2020).

The result of CNS work is often demonstrated through improving efficiency, which at times results in improved patient experience. For example, a palliative care CNS developed a telehealth program that incorporated web-based video conferencing to provide consultation to rural older adults with life-limiting conditions. As a result of this program, there was an increase in the patient satisfaction rate and patients attending visits along with a reduction in cost associated with in-home visits. Although not a replacement for in-person visits, they do provide another alternative to engage the patient and community in their health care (Craswell et al., 2018).

APRN value influence on the safety domain

The safety domain uses data reported from hospital-acquired infections and Patient Safety Indicators 90 measures to calculate the domain score. Hospital-acquired infections include central line–associated bloodstream infections, catheter-associated urinary tract infection, surgical site infections, methicillin-resistant Staphylococcus aureus infection, and Clostridium difficile infection. Patient Safety Indicators 90 is a composite of hospital-acquired pressure injury, iatrogenic pneumothorax, in-hospital fall with hip fracture, perioperative hemorrhage or hematoma, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, perioperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, postoperative wound dehiscence, and unrecognized abdominopelvic accidental puncture/laceration rates. Therefore, APRNs should be well apprised of the current national guidelines for patient care. Actions for the APRN to influence this domain include participation in formal and informal peer review processes including post-event debriefing, post-fall review, and root cause analysis. The APRN should collect ongoing data and monitor their personal clinical practice. This domain calls for APRNs to play a leadership role in the design and implementation of nursing care routines and nurse-driven protocols. As expert collaborators, APRNs can partner with key stakeholders in planning future care environments and care processes to avoid hospital-acquired conditions. Advanced practice registered nurses can use advanced knowledge to identify opportunities as well as strategies for improvement when appraising unit or service dashboards and performance reports. See Table 3 for domain measures and possible APRN strategies to influence this domain. Following are examples of APRN influence within this domain.

Table 3.

Safety domain advanced practice registered nurse (APRN) strategies

Safety Domain	APRN Strategies
Patient safety and adverse events Catheter-associated urinary tract infection Central line-associated bloodstream infection MethiciUin-resistant Staphylococcus aureus Surgical site infection Patient safety indicators 90	Collect data on personal clinical practice Use unit or service dashboards or performance reports Participation in formal and informal peer review processes post-event debriefing post-fall review root cause analysis. Collaborate with key stakeholders in planning future care environments and care processes Actively participate in patient safety focused councils and/or committees

The role of the NP promotes implementation of safe health care. This was evident in an observation study regarding recognition and response to sepsis. In this study, the team addressed sepsis recognition and response by implementing use of a sepsis rapid response team based on a nurse screening tool in the electronic medical record (EMR). Implementation of the program allowed the NP to fulfill the role of the first responder for positive screens, thereby expediting emergent care. This program was associated with a significant reduction in sepsis-related in-hospital mortality. The sepsis associated inpatient death rate was 29.7% before the project and it dropped to 21.1% after the implementation. This program also reported a $2.4 million reduction in cost of care. The authors further reported that this change was sustained throughout the entire time frame of analysis (Jones et al., 2015).

At the core of the CNS role is the promotion of safe high-quality patient care. Hunt and Penoyer (2019) describe a CNS-led practice change to reduce hospital-acquired, device-related pressure injuries in two critical care units. Opportunity was identified to reduce the rate of endotracheal tube–related pressure injuries with a collaborative program of critical care nursing, respiratory therapy, and the wound ostomy care nursing team. As a component of this project, the team implemented use of joint skin assessments in the EMR. By implementing joint assessments that are documented by all three teams, communication and care delivery were improved. The use of variance reports provided feedback to the team regarding further opportunities. Additionally, current evidence regarding frequent repositioning of endotracheal tubes was translated into practice along with a pilot to evaluate other securement devices. To evaluate compliance and staff satisfaction, the CNSs rounded daily to monitor and reinforce the practice and developed an audit tool to evaluate the collaborative documentation and a survey evaluating staff perception of the new process. Once fully integrated into the unit practices, the CNS completed an evaluation of patient outcomes. The program resulted in a 50% reduction in endotracheal tube-associated pressure injuries. Cost of care was reduced by $20,900 to $151,700 per pressure injury (Cefalu et al., 2019).

APRN value influence on the efficiency and cost domain

The efficiency and cost reduction domain uses data from Medicare spending per beneficiary as the fiducial. Centers for Medicare & Medicaid Services uses this domain to recognize hospitals providing high-quality care at a lower cost, increased transparency of cost, and quality of care to consumers. As clinical experts, APRNs should routinely evaluate the cost and economic impact of a plan of care while accounting for alignment in effectiveness and the expected outcome. Advanced practice registered nurses should monitor their practice and validate their contribution to costs averted and cost savings. In many cases, improved quality of care results in a reduction of cost for care provided. See Table 4 for domain measures and possible APRN strategies to influence this domain. Following are examples of APRN influence within this domain.

Table 4.

Efficiency and cost domain advanced practice registered nurse (APRN) strategies

Efficacy and Cost	APRN Strategies
Medicare spending per beneficiary	Collect data on personal practice and set individual performance goal Collaborate with key stakeholders in planning future care environments and care processes

The NP role is to provide patients with high-quality cost-conscious care. This was recently demonstrated by implementation of a NP-driven heart failure service focused on post hospital care, medication titration, and symptom management. When compared with the usual care process at the facility, patients were able to be seen more frequently (every 2 weeks vs. 4–6 weeks). As a result, patients were more likely to attend follow-up appointments. More frequent interactions with a care provider increased patient knowledge base and engagement in self-care. As a result, the total cost of care per patient was reduced by $123 and cost per visit reduced by $164 compared with usual care (Craswell et al., 2018).

As a change agent, the CNS role often results in cost avoidance. For example, a CNS-led initiative to implement a safe patient handling program was initiated to reduce employee injury and associated costs. Although there was an initial need to purchase the equipment, these costs were recovered through reductions in injury rates. To implement this program, the CNS was instrumental in the piloting and purchasing of equipment, policies, and protocols development as well as staff education. Postimplementation data resulted in a 67% reduction in injuries and a 93% reduction in worker’s compensation (from $217K to $17K), reductions in the premiums for worker’s compensation, reduced need for modified work day schedules as well as staff injury frequency and severity perceptions (Cleveland et al., 2019).

Implications for practice

Advanced practice registered nurses seeking guidance for continuous quality care improvement need look no farther than the nursing process for a framework to address gaps in clinical practice or knowledge. This dynamic framework of critical thinking supports evidence informed practice. Additionally, the American Nurses Association (2015) has continued to define standards and competencies for APRNs to remain accountable in their nursing practice cited at beginning of sentence. When APRNs remain engaged in population-specific metrics and quality indicators, they have a unique opportunity to influence HVBP. See Table 5 to correlate steps of the nursing process to APRN actions in influencing HVBP.

Table 5.

Nursing process and advanced practice registered nurse (APRN) actions to support HVBP

Nursing Process	APRN Actions to Support Hospital Value-Based Purchasing
Assessment	Collect data and other information pertinent to clinical practice or patient care
Diagnosis	Analyze the data to determine if there is a gap in clinical practice or patient care
Outcome identification	Identify an expected and measurable outcome
Planning	Design a plan with strategies and interventions
Implementation	Implement the plan
Evaluation	Perform systematic evaluation to determine effectiveness of plan

Although there are numerous barriers to improving clinical practice, overestimation of performance becomes much more obvious when benchmarking against peers. Remaining apprised of current population-specific quality indicators and benchmarking them with one’s actual performance is critical to continuous quality improvement. When perceived performance exceeds actual performance, teams may not place value on the need to implement practice changes (Lin et al., 2015). Identifying and responding to underperformance creates an opportunity for APRNs to demonstrate improvement in quality of care and patient experience metrics.

Finally, APRNs should actively participate in professional organizations and maintain specialty certification in the patient population of focus. These actions are vital tools APRNs use to advance their clinical acumen and validate expert competency in a clinical focus. This proficiency empowers the APRN to influence quality of care and HVBP. Maintaining a professional portfolio of collected evidence including certifications and their impact on the domains is a useful strategy to demonstrate value to a health care organization. Many organizations require routine performance evaluations as a condition of employment. These evaluations are an opportunity for APRNs to document engagement, participation, and leadership in unit or hospital-based projects to validate their contribution to continuous improvement. When APRNs use their advanced knowledge and leadership skills to champion quality improvement and patient experience projects, they also affect financial reimbursement in the HVBP system and thus demonstrate value to the health care institution. Although monetary influence is important to health care systems, one could argue that the real value in quality improvement is making a positive impact on the lives of individuals who are experiencing serious illness.

Conclusions

This article broadly highlights the domains of HVBP and provides several strategies and real-world examples of APRN initiatives that positively influence health care quality metrics and cost of care. Although the domains and measures specific to HVBP are dynamic and change with time, the strategies described in this article remain an effective approach to ensure evidence informs practice and ultimately improves patient outcomes. When APRNs demonstrate leadership, their actions have a direct impact on the HVBP system. Future changes to HVBP will continue to provide opportunities for APRNS to use their expertise to improve clinical outcomes, health care safety, and patient experience while also demonstrating their value to health care systems.