New care coordination codes huge win for nurses

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Alexandra Wilson Pecci, for HealthLeaders Media, November 20, 2012

As people gather together to give thanks this week, nurses, hospitals, and patients have something else to be thankful for: A new Medicare rule that will pay nurses when they help patients make the successful transition from hospitals to other settings.

The new provision can only be described as a huge win for nursing. In fact, if you ask Eileen Carlson, RN, JD, associate director of government affairs for the American Nurses Association, it's one of the biggest things ever to happen in the world of coordinated care.

"Any actions within Medicare or by private payers that reimburse care coordination is a boon for nurses," says Carlson, who was part of the CPT [current procedural terminology] Workgroup that developed the codes.

The rule calls for paying RNs for services that aim to manage patients' transitions from hospitals to other settings and to prevent complications and conditions that cause hospital readmissions. It creates new payment codes for care coordination activities performed by RNs.

New payments will be awarded to nurse practitioners, clinical nurse specialists, certified nurse midwives, and other primary care professionals for "transitional care management" services provided within 30 days of a Medicare patient's discharge from a hospital or similar facility.

To qualify for reimbursement, the primary care professional has to contact the patient soon after discharge, conduct an in-person visit, and engage in medical decision-making. They also have to provide care coordination, which includes effectively facilitating health services and information among a continuum of providers, functions, and settings.

Care coordination has long been a major challenge for hospitals. In the 2012 HealthLeaders Media Industry Survey, 30% of CEOs said care coordination is their greatest strategic challenge. By contrast, improving patient experience (including patient flow) was the next most popular choice, cited as the top strategic challenge by only 17% of respondents.

It's easy to see why getting a handle on coordinated care is so critical for executives: Up to 20% of Medicare patients are readmitted to hospitals within 30 days of discharge, says Carlson.

"That's just horrendous. It's a quality and cost issue," she says, adding that now there's finally a universal recognition that giving the patients what they need when they leave the hospital will help them to actually stay out of the hospital.

"We think these codes are really going to decrease readmissions," she says.

There's already plenty of evidence that care coordination successfully reduces readmissions, lowers costs, and improves patient health. In June, the ANA released a white paper called "The Value of Nursing Care Coordination," which examines recent reports and studies about care coordination and the role of RNs.

For example, one study cited in the white paper found that care coordination leads to better care at a lower cost, particularly for populations with multiple health and social needs. That certainly describes the Medicare population.

On the flip side, another study showed that patient costs of those with uncoordinated care were 75% higher than matched patients whose care was coordinated. That research suggested that care coordination could reduce around a third of costs.

Carlson believes that once people see how much effective care coordination reduces readmissions, Medicare and private payers will start reimbursing even more for it.

Of course, patients and hospitals aren't the only ones who'll benefit from the new codes. Nurses themselves, who play a huge role in care coordination, are also big winners here.

"That shows that there's an understanding of the importance of nurses," Carlson says. "It's nurses who are doing this work."

Moreover, she and the ANA believe that the new codes could also help create jobs. "I see there's a bright future ahead for nurses and care coordinators," she says.

The new care coordination codes definitely should give nurses an extra reason to be thankful this year, maybe even to have a little party.

"We celebrated a little bit," Carlson said with a laugh. "It is a victory."

Source: HealthLeaders Media