Volumne 12, Issue No. 1
February 4, 2014

Hospital CoP & ACO Rules Impact Nursing Practice for RNs and APRNs

Recent decisions by CMS, the Centers for Medicare and Medicaid Services, have a direct and significant impact upon nursing practice and care, for RNs as well as APRNs.  The proposed rule for Medicare Conditions of Participation is open for comments; the rule regarding ACOs is a final rule.  The link to the Federal Register notice of each rule appears after each heading.  ANA comments can be found on our website, Nursing World, at http://www.nursingworld.org/comments.

Conditions of Participation: Nurses can comment by December 23 

Link:  http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf

Conditions of Participation (CoPs) are detailed guidelines hospitals must follow in order to participate in Medicare and Medicaid, designed to protect patient health and safety, and ensure quality of care.  They serve as compliance guidelines for State surveyors and minimum standards for the Joint Commission and other private accrediting bodies.  CMS has proposed significant changes for hospitals and critical access hospitals (at 42 CFR Parts 482 and 485) which directly impact nursing practice and patient care in the several areas.  ANA will share draft comments with the state and constituent nurses associations by the end of November, and we encourage ANA members to consider submitting your own comments; detailed instructions are available in the notice at the link above.

Patient’s Rights (§ 482.13): requires hospitals to notify CMS within 7 days of deaths involving soft two-point wrist restraints, without seclusion; notification within a day would still be required for deaths involving other types of restraints and all forms of seclusion.

Medical Staff (§ 482.22):  Reflecting “the trend of extending patient care responsibilities to practitioners other than doctors of medicine or osteopathy,” including advanced practice RNs, a hospital could grant privileges to physicians and non-physicians outside their medical staff.  The hospital could apply the same requirements, bylaws, and oversight, or create new categories.

Nursing Services (§ 482.23): The nursing care plan could be part of an interdisciplinary plan of care.  Medication orders could be given, documented, and signed by APRNs, PAs, and Doctors of Pharmacy.  Use of standing orders and protocols could expand. Special training would no longer be required to administer blood transfusions and intravenous medications.  Hospitals could allow patients to take some of their own medications, under certain circumstances.

Medical Record Services (§ 482.24):  Authentication of verbal orders would be required “promptly,” but with no particular time frame (like the current 48 hours), and by the ordering practitioner or another practitioner responsible for the patient’s care.  Specific criteria would govern nurses, etc., initiating standing orders.

Infection Control (§ 482.42):  Infection control officers would have flexibility to develop their own systems, and a separate log would no longer be required.

Outpatient Services (§ 482.54):  Hospitals would have more flexibility in management structures for outpatient services.  

Transplant Centers/Organ Recovery and Receipt (§ 482.92):  Streamlines verification and documentation requirements.

Critical Access Hospitals (§ 485):  CAHs could use contracted services in lieu of hiring employees for all services, and “direct services” would become “patient services.” 

Pharmaceutical Services and Infection Control ((§ 482.25, 482.42):  “Quality assurance program” would become “quality assessment and performance improvement program.”

Clinical Nurse Specialist Definition (§ 485.604):  Adopts statutory definition (registered nurse licensed to practice nursing in the State in which the CNS services are performed, that holds an advanced degree in a defined clinical area of nursing from an accredited educational institution).

Surgical Services (§ 485.639):  Clarifies these are optional for CAHs.

Comments also requested on:  Whether the CoPs should be amended to explicitly address: a) Allowing multi-hospital systems to have one single governing body; b) Medical histories and physicals within 30 days prior to admission, by practitioners with and without privileges; and c) the 2012 Life Safety Code standards for hospital physical environments.

Accountable Care Organizations (ACOs) Final Rule

Link:  http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf

The Affordable Care Act created a Medicare Shared Savings Program to reward hospitals, clinicians and other providers who form Accountable Care Organizations (ACOs) for improving coordination, quality and efficiency of care for Medicare beneficiaries.  This rule finalizes and adds new federal regulations for ACO application, approval, operation and payment (at 42 CFR Chapter IV Part 425).  The final rule contains several provisions and changes adopting, or consistent with, ANA’s comment recommendations. 

The “patient-centeredness criteria” and care coordination requirements under section 425.112 are expanded, with additional attention to coordination “throughout an episode of care and during its transitions,” and deletion of references to health information technology as synonymous with care coordination.  Subsection (a)(2) requires an ACO to have a “qualified healthcare professional” who is responsible for the ACO’s quality assurance and improvement program.  The proposed rule had required the program to be “physician directed.”  Section 425.108(c) of the final rule, however, retains the requirement for ACO clinical management and oversight by a “board-certified physician.”

ANA comments strongly expressed the need to preserve patient choice and access to non-ACO providers, particularly advanced practice RNs.  The final rule preserves the inclusion (at §425.20) of nurse practitioners (NPs) and clinical nurse specialists (CNSs) within the definition of “ACO professionals.”  Section 425.304(c)(2) prevents ACOs from requiring referral of ACO patients only to ACO providers, and supports beneficiaries who express “a preference for a different provider, practitioner, or supplier.”  CMS refined its assignment methodology (§425.402) to accommodate beneficiaries who get most of their primary care services from an NP, CNS, or physician’s assistant (PA).  In the notice, CMS specifically recognized their contributions:

“NPs, PAs and clinical nurse specialists (CNSs) have a well-established record of  providing high quality and cost-effective care.  We also agree that these practitioners can be significant assets to the ACO in the areas of quality and cost savings, and indeed that the appropriate use of NPs, PAs and CNSs could be an important element in the success of an ACO.”

Responding to a multitude of comments including ANA’s, CMS reduced the number of quality reporting measures from 65 to 33, and included a measure on readmissions, both of which ANA supported.  The final rule allows Federally Qualified Health Centers and Rural Health Centers to become ACOs ((§425.404), which ANA also endorsed. 

Unfortunately, CMS did not adopt ANA’s suggestions to include nurse-managed and school-based health centers in the incentives; to define care coordination, including recognition of nurse’s key roles in care coordination; to ensure adequate funding and staffing of ACO care coordination functions; and to use nurse-led models of care delivery, such as the American Academy of Nursing’s “Edge Runners” program, as a resource or guidance for ACOs.  We will continue to advocate for these important issues, in future comments and other avenues.

Eileen Shannon Carlson, RN, JD

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