Magazine article Nursing Economics

Developing Staffing Models to Support Population Health Management and Quality Outcomes in Ambulatory Care Settings

Magazine article Nursing Economics

Developing Staffing Models to Support Population Health Management and Quality Outcomes in Ambulatory Care Settings

Article excerpt

PATIENT PROTECTION and Affordable Care Act (ACA, 2010) provisions, such as the expectation all patients will have access to health insurance (regardless of ability to pay and extant prior conditions), primary and preventive care in a patient-centered medical home (PCMH), care coordination, as well as evidence-based care delivered by a health care interprofessional team, have created major challenges in terms of design of staffing patterns, methods, and care delivery models. In addition, the Centers for Medicare & Medicaid Services (CMS) and other insurance providers have devised incentives for delivery of highquality care and penalties for care that does not meet standards. Pay for performance is a quality incentive, while nonpayment for care incidental to occurrence of "never events" in both hospitals and ambulatory care are penalties for poor performance.

As health care delivery moves, however slowly, from fee-for-service where quantity of care reigns, to a "bundled" payment model where quality outcomes are all important, health care systems are now looking at the need to coordinate care across the continuum so they do not lose reimbursement on bundled payments for designated patient populations. This has led to rapid increases in mergers and acquisitions of hospitals and ambulatory care practices. Unfortunately, there is little understanding of how to merge cultures, values, beliefs, and practice in these newly created systems. There is a reluctance to embrace use of evidence-based practice guidelines and team-based care that is seen as a loss of professional autonomy. Also, there is an amazing lack of communication between acute and ambulatory settings. The best example of this is often the primary care provider does not know a patient has been hospitalized until the patient returns for a primary care visit and tells the provider about the hospitalization, at least what is remembered about the hospital visit.

Three of the biggest challenges in ambulatory care settings are (a) who should be on an interprofessional team, (b) how can the team deliver care efficiently and effectively especially to patients with complex chronic illnesses, and (c) how can outcomes of care be specified and captured. Methods to assist in establishing interprofessional teams and models of care delivery by such teams, as well as development of staffing plans for such models in ambulatory settings, are suggested in this article. In addition, staffing models will be discussed using a PCMH as an exemplar, since there are very explicit standards for recognition as a PCMH (see Table 1) (National Center for Quality Assurance [NCQA], 2014).


In ambulatory care settings, staffing should be highly related to the patient population's problem(s), complexity, and needs; currently ambulatory care is moving rapidly to population health management, whereas acute care tends still to be focused on the individual. Furthermore, health care needs of patients in ambulatory care are often complicated by social determinants such as education level, health literacy, financial status, level of social support, living situation, as well as mental health problems that may be intertwined with the presence of addiction to drugs and/or alcohol.

The context of care delivery in ambulatory settings differs greatly from acute care. In acute care, hospital-centered health care professionals provide the care and thus are in control of care 24/7. In contrast, in ambulatory, the patient and/or family or significant others provide and control care, while health care providers engage, facilitate, educate, and coach patients and families who are caregivers. The focus of care and documentation in ambulatory settings is the patient encounter. Traditionally, ambulatory care settings specified weekday hours for patient encounters with providers in a clinic setting; only recently have ambulatory clinics set up evening and weekend hours and some have instituted walk-in clinics. …

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