Packet 5:

Chapter 25 and
26
 Chapter 25

Care Delivery Across

the Care Continuum:
Hospital–Community–
Home
 Introduction
This chapter focuses on a little known, often overlooked, and poorly understood
segment of our healthcare system—post-acute care. As decision-makers in care planning and
care coordination, nurses’ and physicians’ formal education often does not include training in
these clinical settings nor is the subject covered adequately in curriculum. Consequently,
many health professionals carry an insufficient understanding of the post-acute care
providers and how they can augment their care plan for a given patient. As we move into the
new health reform initiatives mandated under the Patient Protection and Affordable Care Act
(ACA) (United States Congress, 2010), a major challenge in achieving the Triple Aims of
increased quality at reduced costs, improved patient experience, and improved population
health is our ability as a healthcare system “to integrate its work over time and across sites of
care”
 HEALTHCARE REFORM
The fragmentation of the United States (U.S.) healthcare delivery
system is well documented. And despite the United States having the
highest spending per person of all the industrialized countries, it falls
below the majority of the Organization for Economic Co-operation and
Development (OECD) nations on major health indices, including having
the highest rates for obesity. Similarly, the United States has the highest
spending per GDP (Gross Domestic Product) of the OECD nations, 17.7%
compared to the next highest country, the Netherlands, at 11.9%. The
imperative to reform our healthcare system is driven by these economics.
 Development of the National Strategy for Quality Improvement

The current reform framework and changes in reimbursement policies have been pushed
forward by a number researchers, private institutes, and government agencies building upon each
other’s work. Most notable are the contributions from Berwick and colleagues from the Institute of
Healthcare Improvement and the work of the Commonwealth Fund’s Commission on High
Performance Healthcare. Taken together, these two bodies of work redefined what should be the
focus of care delivery—the Triple Aims and detailed how a “high performance healthcare system”
needs to operate and deliver care to achieve value. This reform framework, first published by the
Agency for Health and Quality Research (AHRQ) in March 2011 as the National Quality Strategy
(NQS), is based on a translated version of IHI’s triple aims of “better care, healthy people/healthy
community, and affordable care” and six priorities that target making care safe, coordinated, based
on evidence of clinical effectiveness, development of new care delivery and reimbursement
models, and community level focus for healthier living.
 Affordable Care Act’s Operational Arms
The two most influential health policy bodies created by mandate of the 2010
Affordable Care Act (ACA) are the CMS Innovation Center and the Patient-Centered
Outcomes Research Institute (PCORI). The CMS Innovation Center is focused on patient
populations using Medicare, Medicaid, or Children’s Health Insurance Program (CHIP).
PCORI funds comparative clinical effectiveness research on treatment methods, drugs,
devices, and systems, and mechanisms for the rapid dissemination of these research findings
for them to be put into practice Funding levels for the first three years of PCORI from 2010
to 2013 was $316 million for 192 studies, with the next three years funded at $1.5 billion.
These two important HHS health policy entities are driving rapid change within our
healthcare practice structures linked as they are to new reimbursement incentives and
penalties.
 INTRODUCING THE POST-ACUTE PROVIDERS

It can be confusing and difficult to those outside of the post-acute care sector to differentiate
between the unique services each provides from those that overlap. While not the sole providers of
post-hospital care, traditionally CMS includes home health agencies, skilled nursing facilities,
inpatient rehabilitation facilities, and long-term care hospitals in this “post-acute care” category. To
assist in this overview, Table 25.1 lists each CMS recognized entity, the type of patient services
provided, differences, patient eligibility requirement, payment structure, and episode period.
Medicare and Medicaid pay the significant portion of care expense for care delivered in the post-
acute sector. The Medicare benefit pays for skilled care, therapy, and other services delivered by
inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), long-term care providers
(LTCH), home health agencies (HHA), and hospice. Patients accessing the post-acute providers
instead of ambulatory centers or clinics are those who are homebound, or have need of inpatient
level of care, have restricted mobility, or are at six months or less at end of life.
TABLE 25.1
 The Role for Post-Acute Care Providers
Increasingly, as Care Transitions demonstration projects mandated under the 2010
Affordable Care Act (ACA) have generated lessons learned in care coordination, other post-acute
care providers, such as Hospices and Kidney Dialysis Centers, have started to be included in
planning. For example, in Care Transition partnerships between home health agencies (HHA) and
hospitals, these teams quickly learned how imperative it was to have a clinical profile tool with
risk criteria that could differentiate and identify individuals at the “end-of-life” stage of a chronic
disease from those with longer term trajectories. Without this specificity, these terminal patients
were referred to providers with a rehabilitative or curative mandate post-discharge, such as home
health or a Skilled Nursing Facility (SNF). Because these patients are those projected as having a
six months’ life expectancy, they are inherently not medically stable and the result is frequent
Emergency Room visits and rehospitalizations.
 CLINICAL INFORMATION SYSTEMS IN POST-ACUTE CARE

Just as Meaningful Use (MU) incentives are impacting acute and ambulatory
care providers, they are also affecting the post-acute care providers even though
they are not included as eligible providers for payment incentives. Under MU,
hospital organizations and physician offices are financially rewarded to adopt and
use EHR functionality. In just over a decade, EHR adoption has profoundly
impacted how clinicians work, document, and use data in support of clinical
decisions and care planning in these settings. Accordingly, expectations for data
exchange and empowering data analytics are expanding beyond the medical
center and are being placed upon the post-acute care community
 Majority of post-acute organizations have information systems that include
clinical documentation, these are designed largely to function as data captures for
billing and CMS’ mandatory minimum data base sets. Each post-acute provider has a
mandatory minimum data set that must be submitted to CMS at regular intervals for
each patient admission and discharge (see Table 25.1) as a condition for
reimbursement by CMS. This regulatory requirement has driven the way systems have
been built for the post-acute market over the past 30 years and is fundamental to
understanding the current state. Home health illustrates this evolution and why there is
a lack of functional parity between the EHR systems serving the post-acute market as
compared to those for acute and ambulatory care.
 EHR Adoption Levels in Home Health
From 2000 to 2013, there have been three national surveys conducted on the
levels of EHR adoption in the home health industry. These are the 2000 National
Home and Hospice Care Survey (NHHCS), the 2006-2007 American Association of
Homes and Services for the Aging and Fazzi Associates’ 2013 survey of over 1000
HHA agencies.
 Missing from these benchmarks, however, is the degree to which the
specific functionality that is basic to EHR standards today is in the systems
being used. This functionality includes clinical decision support; flexibility of
views of patient care information; point-of-care support for clinical
documentation; telemedicine and standardized, structured terminologies; and
ability to send and receive patient information with other external providers.
 STANDARDS NEEDED FOR CARE COORDINATION

Standards for clinical information systems apply to the ways data are named,
stored, and shared as well as to promote accuracy and to work more efficiently.
Ultimately, standardized systems can improve patient safety and lower healthcare
costs. When aspects of care coordination are standardized, it is easier to collect data
and share data pertinent to care across multiple sites by various care providers. Care
Coordination has been a topic of interest for standard development and
implementation organizations for many years, such as the ONC Standards &
Interoperability Framework, and by non-profit agencies such as Health Level 7 (HL7),
and Integrating the Healthcare Enterprise (IHE).
Another major focus of Standards Development Organizations (SDO)
has been defining the shared care plan. The care plan has great
potential for facilitating coordination of care across settings and
between multiple disciplines. It is one centralized location where all
care team members can see a patient’s individualized health goals
 DISCUSSION

● U.S. healthcare spending puts an unsustainable burden on taxpayers who fund

Medicare and Medicaid, employers who fund healthcare insurance as an
employment benefit, and individuals doing self-pay. If the Healthcare Exchanges
mandated under the 2010 Patient Protection and Affordable Care Act become an
operational reality, then the United States will lose the dubious distinction of
being the only industrialized nation that does not provide universal health
insurance to its population.
● Effective care coordination requires well-defined multi-disciplinary
teamwork based on the principle that all who interact with a patient must
work together to ensure the delivery of safe, high-quality care.
● The U.S. healthcare system is in the process of dramatic and rapid change. Health
policy and reimbursement reform is being driven on multiple legislative and
regulatory fronts. The areas most impactful to the post-acute care sector are those
under the National Quality Strategy’s priority for care coordination and the
management of care transitions. These aims and priorities are currently defined
through readmission outcome metrics that are linked to significant CMS
reimbursement penalties.
● Informatics has a major role to play in reaching the NQS goals of a healthcare system
that delivers value for money spent and a healthier population. Detailed information
technology requirements are needed for functionality that must be in place in a cross-
continuum to support care coordination, communication and access data collection,
measurements, and reporting—all infrastructure capabilities that are missing in some
degree in our electronic health records (EHR) systems today across care settings
● Nursing and nursing informatics are optimally positioned to be leaders in the teams
that design, build, and implement these new health and IT systems that enable care
coordination.
 Chapter 26

Foundation of a Nursing
Plan of Care Standard
Nursing Special Interest Group (SIG)

- was initiated in 2006 within the Integrating

the Healthcare Enterprise (IHE), an
International Standard Development
Organization, to reflect the importance of
communication integrity and continuum of
care during patient/ client transfers. The
Institute of Medicine has identified the
highest risk of errors affecting patients
occur at the point-of-care transfer.
 The Nursing Sub-committee
began moving forward with a
profile to demonstrate use of
nursing process to illustrate
documentation of plan of care
elements illustrating patient
progress along the health-illness
continuum (Dickerson & Veenstra,
2010). This focus was demonstrated
in 2010 when a nursing plan of care
(PoC) profile standard was
successfully balloted as a patient
plan of care (PPOC). However,
because the PPOC did not specify
nursing it has been interpreted by
IHE members as referring to all
health professionals providing care
to a patient even though the PPOC
used a nursing terminology, Clinical
Care Classification System, and
followed the nursing process as
illustrated in Fig. 26.1.
 Federal Initiatives
Federal government began to focus on computer based healthcare
technology with the Institute of Medicine (IOM) report on The
Computer-based Patient Record (Institute of Medicine, 1997). The
IOM asserted that the computerization of the patient records
could improve the quality and safety of patient care. This
landmark document as well as the To Err in Human (IOM, 1999)
and Preventing Medication Errors (IOM, 2006) reports affirmed
that electronic healthcare record systems could reduce the number
of medication errors and death in hospitals and prevent
medication errors.
 Federal Initiatives

These reports and numerous other initiatives addressing

this issue led to Executive Order No. 13335, “Incentive for
the Use of Health Information Technology and
Establishing the Position of the National Health
Information Technology Coordinator” that established the
Office of the National Coordinator (ONC) (Exec. Order
No 13335, 2004).
Development of
a Nursing Plan
of Care
 Development of a Nursing Plan of Care

The informatics nurses engaged in HITSP, solicited the Integrating the

Healthcare Enterprise (IHE, 2008) to use the HITSP selected nursing
terminology, and developed a methodology for the documentation of patient
care. As a result, the Nursing Plan of Care (PoC), under the name of the
Coded Nursing Documentation Plan of Care, was proposed and accepted by
IHE as a New Work Item Proposal (NWIP). The NWIP underwent additional
development by nursing and technical experts and using the consensus
process was publicly vetted under the name of the Patient Plan of Care
(PPOC) that recognized the patient-centric focus of healthcare (Fig. 26.1).
Patient Plan of
Care (PPOC)
 Patient Plan of Care (PPOC)
The PPOC is an IHE profile describing the data concepts needed by nurses for
documentation in the electronic health record. The Patient Plan of Care (PPOC)
explicitly formalized the data requirements of nurses for the efficient and timely
capture of care events at or near the bedside acknowledging the patient-centric
healthcare environment.

The PPoC provided the context for nursing data using common scenarios
following the American Nurses Association (ANA) Nursing Process standard (six
phases) represented by the information model and terminology (vocabulary) of
the CCC System.
 The CCC System was used repeatedly as an exemplar
of structured, coded, nursing terminology. The use of
CCC the CCC System for the IHE profile standard was an
extension of the interoperability conformance
System. recognition of the CCC by Health Level Seven (HL7)
interoperability for electronic transmission and the
integration of the CCC System in the Unified Medical
Language System (UMLS) for all clinical settings.
The CCC, specifically designed for computer-based
systems, conforms to the Cimino criteria for
standardized terminology (Cimino, 1998).
 CCC System
The Nursing PoC standard used the CCC System
to name, describe, and code the nursing “essence
of care” which refers to “documentation of the
primary reason including the essential nursing care
needs” (Saba, 2007) for providing patient care for
a specific condition.
Currently in the Meaningful Use (MU) requirements Meaningful Use
(Office of the National Coordinator for Health
Information Technology, n.d.) is the term Eligible
Professionals (EPs) and defined by CMS as “responsible
for the diagnosis and treatment of patients prescribing
medications, laboratory tests, radiology procedures,
other care modalities, activities and services” (U.S.
Department of Health and Human Services, 77 FR
53967, 2012).
The definition in the regulation encompasses
traditional nursing practice responsibilities:

(1) Provide individualized patient care,

(2) Coordinate care with other
providers,
(3) Provide caring practices,
 (5) Provide quality healthcare and achieve
(4) Use the nursing process optimal outcomes. Professional nurses are
(integration of sinular actions of also responsible for the implementation of
assessment, diagnosis, and medical provider orders and the
collaboration with allied health
identification of outcomes, planning,
professionals:
implementation, and evaluation) to
provide and document patient care, - Physical,
and - Occupational,

- Respiratory,

- Speech Therapists, etc.

 Meaningful Use Stages 1 and 2

Initially, one of the four proposed denominators in the Stage 1 MU

objectives omitted and excluded the eligible providers of patient care
and/or the caring process (Whittenburg & Saba, 2012). As stated above,
the MU focus was on provider orders for reimbursable special services in
Computerized Provider Order Entry (CPOE) systems. For example:
“Number of orders for medications, laboratory tests and radiology” were
entered in the EHR system and if the application was implemented
success fully, the hospital/facility received federal funds from the ONC
technology program. The process continued in MU Stage 2 and which
focused on quality indicators.
 How a Nursing Plan of Care Could Impact
By adding a Nursing PoC to the MU “Number of Orders” denomination, the denominator
could standardize the various terms used to describe the care process: care plan, plans of
care, treatment plan, etc. Second, the Nursing PoC using the Nursing Process framework
provides a complete minimum requirements for a care plan field: “problem” (focus of the
care plan) with

(1) Assessment,

(2) Diagnosis,

(3) Goal (target outcome)/ Expected Outcome,

(4/5) Planning and Implementation (“instructions” for Interventions and Actions), and

(6) Expected Outcome (target or measure/outcomes achieved).

Third, with the Nursing PoC included in the MU patient care
reporting, the Nursing PoC could generate a status report of the
status of the patient at any point in time, updated and revised based
on specific clinical requirements, and addressed in the clinical
decision support systems. For CMU and MU, the Nursing PoC
offered a readily available standard to summarize the quality care as
part of each Clinical Quality Measure’s Description (based on six
phases) for the transition of care (ToC) along the continuum of care.
The recommendation was deferred to MU Stage 3.
 Meaningful Use Stage 3

Meaningful Use Stage 3 is poised to identify the

requirements for care coordination and sharing of
information across multiple provider groups—from
long-term care and post-acute care to behavioral
health and other allied services (Whittenburg &
Saba, 2012).
 Meaningful Use Stage 3

The identification and harmonization of standards for the longitudinal coordination of care
will improve efficiencies and promote collaboration by:
• Improving provider’s workflow by enabling secure, single-point data entry
for the Transfer of Care (ToC) and Care Plan exchange including a Nursing
PoC

• Eliminating the large amount of time wasted in phone communication and

the frustrations and dissatisfaction of the receiving provider in not always
obtaining care transition and care planning information in a timely manner.
 Meaningful Use Stage 3

The identification and harmonization of standards for the longitudinal coordination of care
will improve efficiencies and promote collaboration by:
• Reducing paper and fax transmissions, and corresponding labor intensive,
manual processes during a ToC or Care Plan exchange including a Nursing
PoC
• Supporting the timely transition of relevant clinical information at the start
of home healthcare and as the patient’s condition changes
• Enabling sending and receiving provider groups to initiate and/or
recommend changes to patient interventions more promptly
NURSING PLAN OF
CARE FRAMEWORK
AND NURSING PROCESS
 NURSING PLAN OF CARE FRAMEWORK AND NURSING PROCESS

The theoretical framework for a fully operational Nursing PoC is the

Nursing Process. “The common thread uniting different types of
nurses who work in various areas of nursing practice is the nursing
process— the essential core of practice for the registered nurse to
deliver holistic, patient-focused care” (ANA, 2010). The Nursing
Process encompasses all significant nursing actions—the process
forms the foundation of the nurse’s professional practice and
decision-making.
 NURSING PLAN OF CARE FRAMEWORK AND NURSING PROCESS

The Nursing Process is the standard of practice and includes the

following six phases: assessment which includes the collection of
comprehensive data pertinent to the patient’s health or condition.
The data are then analyzed to determine the nursing diagnosis or
problem. The nurse then identifies the expected outcomes (goals) for
each diagnosis for development of a care plan to attain the expected
outcomes. The registered nurse implements the identified plan with
ongoing evaluation of progress toward the attainment of the
identified outcomes (Fig. 26.2).
 NURSING PLAN OF CARE FRAMEWORK AND NURSING PROCESS

The nursing process focuses on patient

care processes provided by nurses and
allied health personnel in clinical
practice settings (Saba 2007, 2011).
 Other characteristics of the Nursing PoC and Nursing Process
framework include:

Universally Applicable: Nursing Process framework is appropriate

for any patient, of any age, with any clinical diagnosis, at any point
on the health continuum, and in any setting (e.g., school, clinic,
hospital, or home) across all nurse specialties (e.g., hospice,
maternity, pediatric, etc.).
Goal-oriented: Nursing Process interventions are determined by the
nursing diagnoses and chosen for the purpose of achieving the
nursing outcome.
Cognitive Process: Nursing Process in
volves nursing judgment and decision-making.
CARE PLANNING
PROPONENTS
 Health Level Seven International (HL7)
Health Level Seven International (HL7) is a Standard Development
Organization that states: “Care planning is a conceptual framework with
many interrelated dependencies and antecedents” (Outstanding Issues, n.d.,
para 1). The HL7 Nursing Sub-committee is collaborating with the IHE
Patient Care Coordination (PCC) Committee on the details of a Care Plan
that can be used by all healthcare professionals. The committees are
discussing the “significant confusion and extensive debates over the different
types of Care Plans: Care Plan, Plan of Care, and Treatment Plan”
(Introduction, n.d., para 1). Such care plans are likely to be understood and
used in different ways depending on the preference, context of use, funding
model, etc., under which they operate.
 Standards and Interoperability Framework

The Standards & Interoperability (S&I) Framework

approach from the Office of the National Coordinator for
Health Information Technology (ONC), Office of
Standards & Interoperability, is another initiative to
create better care, better health, and cost reduction by
care delivery improvements (Berwick, Nolan &
Whittington, 2008).
 HEALTHCARE INFORMATICS STANDARD GROUPS

The interest and involvement of the Standard Development

Organizations (SDOs) in demonstrating the implementation of data
terminology standards for nursing care across all settings of care is
crucial to providing the evidence of nursing care out comes. The
catalyst for the Nursing PoC is the six standards or Phases of the
nursing process for documenting professional nursing practice using
a standardized nursing terminology such as the CCC System.
Descriptions of key informatics groups focusing on Meaningful Use
standards are summarized below.
 Office of the National Coordinator for Health
Information Technology
The Office of the National Coordinator for Health Information
Technology (ONC; www.healthit.gov) is a division of the Office of the
Secretary, U.S. DHHS with a focus on coordinating the adoption,
implementation, and use of health information technology, including the
electronic exchange of health information, to achieve the “Triple Aims
Framework” of reform:

1) “Better Care: (improve the overall quality, by making health care

more patient-centered, accessible, and safe);
 Office of the National Coordinator for Health
Information Technology
2) Healthy People/Health Communities: (Improve the health of the U.S.
population by supporting proven interventions to address behavioral,
social, and environmental determinants of health in addition to delivering
higher-quality care); and

3) Affordable Care: (Reduce the cost of quality health care for

individuals, families, employers, and government reducing per capita
costs of health care) (Health Information Technology [HIT] Policy
Committee, 2011).
 Standards & Interoperability Framework (S&I
Framework)

The Standards & Interoperability (S&I) Framework

(http:// www.siframework.org) was formed to enable
health care stakeholders to improve the quality of
healthcare through greater health information
exchange.
The S&I Framework has two key initiatives
involving care plans:

S&I Longitudinal Coordination of

Care (LCC)
S&I Transition of Care (ToC)

-initiative that is focused on initiative created to identify and develop

healthcare standards that would enable the
improving the transitions of electronic exchange of core clinical
patients across acute and information among providers, patients, and
other authorized entities to meet Stage 1
post-acute care settings and Stage 2 MU ToC requirements.
 REFERENCES
Chapter 26:Foundation of a Nursing Plan of
Care Standard page 385 to 393, Luann
Whittenburg / Virginia K. Saba, Retrieved
from Essentials-of-Nursing-Informatics-
6th-Edition.pdf
END.
Thank you!