Identify at least three major factors that contributed to the shift to ambulatory care services. Explore the implications of this shift for ambulatory care facilities, healthcare providers and physicians, consumers, and possible healthcare career focus.Be specific and provide detailed examples to support your major points.


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Perspectives in Ambulatory Care
Rosemarie Battaglia
Rachel Start
Mary Morin
Ambulatory Care Nurse-Sensitive Indicators Series:
Starting with Low-Hanging Fruit: Proposing the Adaptation
Of Health Care Measures to the Role of the Nurse in
Ambulatory Care
The American Academy of Ambulatory Care
Nursing’s Nurse-Sensitive Indicator Task Force was
charged with identifying and developing meaningful
measures for the ambulatory care environment.
Several strategies were used to identify measures
that would reflect the value of the role of the nurse in
this setting.
One such strategy was to conduct a comprehensive
review of the health care environment as a whole and
the measures within it, to identify measures that
already existed that could easily be adapted to the
role of the nurse in ambulatory care settings.
Because of the complexity of the ambulatory care
patient care environment, the group sought to reach
momentum in indicator development by starting with
the proposal of measures that would be less complex
to develop, pilot, and adapt in organizations across
the country.
APRIL 2016, the American Academy of Ambulatory Care Nursing (AAACN) published an
important report entitled, Ambulatory Care
Nurse-Sensitive Indicator Industry Report: Meaningful Measurement of Nursing in the Ambulatory
Patient Care Environment (Start, Matlock, & Mastal,
2016). Within this report is a review of the current
and future landscape of health care, particularly as it
impacts the nurse in ambulatory care and community
settings, a review of existent nurse-sensitive indicators in the ambulatory care setting, and 13 proposed
ROSEMARIE BATTAGLIA, MSN, RN, is Nurse Manager, Children’s
Hospital, Medical University of South Carolina, Charleston, SC.
RACHEL START, MSN, RN, NE-BC, is Director, Ambulatory
Nursing, Nursing Practice, and Magnet® Performance, Rush Oak
Park Hospital, Oak Park, IL.
MARY MORIN, RN, NEA-BC, RN-BC, is Vice President and Nurse
Executive, Sentara Medical Group, Norfolk, VA.
NURSING ECONOMIC$/July-August 2016/Vol. 34/No. 4
nurse-sensitive indicator topics identified for meaningful measurement of the value of the nurse in these
Health care delivery has been shifting from the
inpatient to the ambulatory care setting, with significant growth in the primary care population (Start et al.,
2016). According to the American Hospital Association
(AHA, 2015), inpatient admissions have decreased
from 11.93% in 1993 to 10.63% in 2013, and the average length of stay has reduced from 7 days in 1993 to
5.4 days in 2013. Meanwhile, outpatient visits averaged 14.22% in 1993 and increased to 21.45% in 2013
(AHA, 2015), while the registered nurse (RN) workforce in the outpatient setting, particularly in primary
care, has declined (Institute of Medicine [IOM], 2010).
The Patient Protection and Affordable Care Act of 2010
encourages growth of the primary care workforce by
reimbursing for primary care, empowering community
health centers, and establishing mechanisms to manage complex, high-risk patients, keeping them out of
the hospital. Various elements of the current health
care system need transformation and because of the
close proximity and holistic perspective of nurses
throughout the care continuum, the IOM in its landmark report, The Future of Nursing: Leading Change,
Advancing Health, encouraged nurses in all roles and
settings to take the lead in this transformation (IOM,
2010, 2015).
The AAACN Nurse-Sensitive Indicator (NSI) Task
Force (TF) believes the empowerment of nurses in the
ambulatory care environment is necessary to meet the
coordination of complex care to the growing patient
population. To date, measurement of the role of the
ambulatory care nurse has been underdeveloped and
not focused on the meaningful role nurses play in the
primary care and specialty practice settings. The NSI
TF sought to identify measureable topic areas that
would quantify the RN as a leader and transformer in
this setting (Start et al., 2016). Throughout the 3 years
in which this work was addressed, one goal was to
identify measureable topic areas that would be “lowhanging fruit,” or easy to develop and adapt in all
NOTE: This column is written by members of the American
Academy of Ambulatory Care Nursing (AAACN) and edited by Kitty
Shulman, MSN, RN-BC. For more information about the organization, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ
08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 5897463; Email: aaacn@ajj.com; Website: http://AAACN.org
organizations as well as be meaningful across a variety
of settings in ambulatory care. Additionally, the NSI
TF remained committed to the proposal of measures
that would be applicable across the patient’s lifespan.
This column and those that follow will describe measures proposed, either adapted from already existing
health care measures or novel, by the NSI TF to meet
this need. A total of 13 measures have been proposed
and are now being prioritized for development and
benchmarking. This process will occur over the next
several years through the partnership AAACN has
with the Collaborative Alliance for Nursing Outcomes
(CALNOC). CALNOC’s scientific history with measure
development, validation, and benchmarking will provide the expertise needed to get these measures into
the ambulatory care environment.
Comprehensive Review of Measurement in the
Ambulatory Setting: Finding the Low-Hanging Fruit
The purpose of the NSI TF’s Industry Report
(Start et al., 2016) was to describe the current health
care environment, the role nurses are required to play,
and whether any measures existed for current use in
a benchmarking format for ambulatory care nurses.
Throughout the process there were continual
attempts to find measures that were low-hanging
fruit. Because of the complexity of staffing, diversity
of RN roles, and variation of electronic medical
and/or paper records, the quest to identify meaningful measures was difficult. Several of the measures
described in this article represent measures that will
be easier to develop and eventually benchmark than
others that are more complex.
A comprehensive review of measures within
common databases such as The Centers for Medicare
& Medicaid Services (CMS), Accountable Care
Organization, National Quality Forum (NQF), and
Physician Quality Reporting System (PQRS) was
completed. When this analysis was then paired with
the evidence-based literature, best practice, and
expert reviews the task force conducted, several nonnursing-specific health care measures surfaced as
potentially meaningful measures of nurse quality in
the ambulatory care environment. Nine measures
were further evaluated by subgroups within the NSI
TF who split them up, performing additional literature reviews to support them and providing the
ambulatory care nurse-sensitive indicator proposal
language for future development and benchmarking.
The proposed nine measures that were adapted from
existing health care measures are reviewed in this column. The NSI TF proposes they all should be analyzed for development and eventual benchmarking.
Measures Adapted and Recommended as Ambulatory
Care Nurse-Sensitive
The nine adapted measures proposed in section
three of the AAACN Industry Report (Start et al.,
2016) are described in each subsection below. The
title of each subsection is the name, as listed in the
report, of each proposed measure. As these measures
move through the development phase of the AAACN
and CALNOC workgroup they will likely be shifted,
further defined, and/or split into multiple separate
measures for feasibility, validity, and greater reliability. Table 1 lists the key measurement descriptors along
with the measures from which they were adapted.
Ambulatory Care Nurse Readmission Across the
Lifespan. Acute care hospital readmissions are costly
and often preventable (Horwitz et al., 2011). The Commonwealth Fund estimates if national readmission
rates were lowered to the levels achieved by top-performing regions, Medicare would save $1.9 billion
annually (CMS, 2015a). In both the pediatric and
adult populations, evidence suggests readmissions
are linked to decreased quality of care, lack of care
coordination, or other factors within the control of
health care clinicians (Horwitz et al., 2011). An initial
readmission measure was created by Yale for CMS
and endorsed by NQF. This measure is entitled #1789
“Hospital-Wide, All-Cause, Unplanned Readmission
Measure.” It is specific to patients aged 18 years and
older, estimating the hospital-level, risk-standardized
incidence of unplanned, all-cause readmissions for
any eligible condition within 30 days of hospital discharge for these patients (NQF, 2015a). NQF has also
endorsed a pediatric all-condition readmission measure, NQF #2393, developed from the Center of Excellence for Pediatric Quality Measurement. This
measure was commissioned and developed as part of
the Agency for Healthcare Research and Quality (AHRQ)
and CMS Pediatric Quality Measures Program (NQF
2015b; Start et al., 2016).
The NSI TF believes RN care coordination includes sociocultural as well as disease-specific
knowledge and competencies and medication management principles, all of which have the strong
potential to decrease emergency department and hospital readmissions (Start et al., 2016). The AAACN
NSI TF further believes improved inpatient to outpatient handoffs and care coordination would improve
readmission rates. Adaptation of these functions into
a proposed measure that includes several high-risk,
chronic patient populations will reflect the role the
RN plays in the community and ambulatory care settings in reducing readmissions.
Ambulatory Care Nurse Pain Assessment and
Follow Up. Approximately 76.5 million Americans
suffer from pain, the number one reason Americans
pursue health care (Start et al., 2016). Uncontrolled or
undertreated pain diminishes quality of life while
increasing health care costs and disability claims
(CMS, 2015b). There are significant disparities related
to pain perception, assessment, and treatment among
racial and ethnic minorities (CMS, 2015b).
Chronic pain assessment should include deterNURSING ECONOMIC$/July-August 2016/Vol. 34/No. 4
Table 1.
AAACN NSI Task Force Proposed Indicators for Development of Ambulatory Care
Nurse-Sensitive Indicator Measures
Measure Name
Ambulatory Care
Across the
Measure Description
Risk-adjusted percentage of Accountable Care Organization (ACO)-assigned
beneficiaries who were hospitalized who were readmitted to a hospital within 30
days following discharge from the hospital for the index admission.
• Percentage of patients in one of below identified populations that receive a
post-discharge call within 48 hours of emergency department visit or after an
inpatient stay from an ambulatory care nurse responsible for care coordination
of that patient.
• Percentage of patients in one of below identified populations that are
readmitted within 30 days of discharge from inpatient setting.
Adapted From
NQF 1789
NQF 2393
Respiratory: Asthma/Respiratory syncytial virus/Pneumonia
Cardiac: Congenital cardiac/Heart failure
Endocrinology: Diabetes
Blood disorders: Sickle cell
Neurology: Seizures
Primary Care: Hypertension, pain, depression, falls, obesity
Ambulatory Care
Nurse Pain
Assessment and
Follow Up
Ambulatory Care
Nurse Screening
for High Blood
Pressure and
Follow-up Care
Ambulatory Care
Nurse Screening
and Follow-Up
Documentation for
Ambulatory Care
Nurse Patient
Falls in the
Ambulatory Care
Nurse Screening
for Future Falls
Respiratory: Chronic obstructive pulmonary disease
Cardiac: Heart failure
Endocrinology: Diabetes
Blood disorders: Sickle cell
Neurology: Stroke
Primary care: Hypertension, pain, depression screening, falls, obesity
Percentage of patients of all ages with documentation of a pain assessment
through discussion with the patient including the use of a standardized tool(s) on
each visit and documentation of a follow-up plan when pain is present.
NQF 0420
PQRS 131
• Percentage of patients in one of the identified populations that received a
depression screening during a visit encounter.
• Percentage of patients in one of the identified populations who screened
positive and have a follow-up plan of care for depression.
CMS 2v3
ACO 18
NQF 0418
Percentage of patients who were screened for future fall risk at least once within
12 months.
ACO 13
NQF 0101
PQRS 154
Percentage of patients at all ages seen during the measurement period who were ACO 21
screened for high blood pressure and a recommended follow-up plan is
NQF 0018
documented based on the current blood pressure reading as indicated.
• Percentage of patients in one of the identified populations that received a
blood pressure screening during a visit encounter.
• Percentage of patients in one of the identified populations who have a followup plan of care for hypertension.
All documented falls, with or without injury, experienced by patients on eligible
unit types in a calendar quarter. Reported as total falls per 1,000 patient visits and Press
unassisted falls per 1,000 patient visits.
NQF 0141
NURSING ECONOMIC$/July-August 2016/Vol. 34/No. 4
continued on next page
Table 1. (continued)
AAACN NSI Task Force Proposed Indicators for Development of Ambulatory Care
Nurse-Sensitive Indicator Measures
Measure Name
Measure Description
Adapted From
Ambulatory Care
Nurse Screening
for Body Mass
Index (BMI)
Percentage of patients with a calculated BMI in the past 6 months or during the
current visit documented in the medical record and if the most recent BMI is
outside of normal parameters, a follow-up plan is documented within the past 6
months or during the current visit.
ACO 16
NQF 0421
Ambulatory Care
Nurse Patient
The percentage of surveys that were returned within a defined period and of
questions that are nursing specific and answered by the patient as “always.”
Press Ganey
Risser Patient
Satisfaction Survey
PPE 15
Ambulatory Care
Nurse RN
% Diploma RN FTE
% Associate’s degree RN FTE
% Bachelor’s of science degree RN FTE
% Master’s of science degree RN FTE
% Doctorate in nursing degree RN FTE
% Certified RN FTE
% Certified RN in specialty field FTE
% Turnover RN by FTE
% Vacancy RN by FTE
SOURCE: Start et al., 2016
NOTES: ACO = Accountable Care Organization, BMI = body mass index, CALNOC = Collaborative Alliance for Nursing
Outcomes, CG-CAHPS = Clinician and Group Consumer Assessment of Healthcare Providers and Systems, CMS = Centers for
Medicare & Medicaid Services, FTE = full-time equivalent, GRPO = group practice reporting option, NDNQI = National Database
of Nursing Quality Indicators, NQF = National Quality Forum, PSQ = Patient Satisfaction Questionnaire, PQRS = Physician
Quality Reporting System, PPE = Picker Patient Experience Questionnaire, RN = registered nurse
mining the mechanisms of pain through documentation of pain location, intensity, quality, onset, and
duration, as well as functional ability and goals, and
psychological and social factors such as depression or
substance abuse (Hooten et al., 2013). PQRS Measure
#131, “Pain Assessment and Follow Up,” from which
this ambulatory care nurse-sensitive measure was
adapted, states performance of these activities may be
reported by eligible professionals who participated in
the quality actions described in the measure (CMS,
The NSI TF believes pain assessment and follow
up to be central to the role of the RN and as such, this
measure, if adapted to the ambulatory care RN, may
be a meaningful reflector of the role of the RN to
patient care in the ambulatory care setting (Start et al.,
2016). This measure applies to patients throughout
the lifespan, is critical to care coordination, and can
have an impact on the promotion of health.
Ambulatory Care Nurse Screening for High
Blood Pressure and Follow-Up Care. Hypertension is
a chronic condition that puts patients at high risk for
development of heart disease, stroke, and other dis202
eases that can result in premature death (Kung & Xu,
2015). Reducing the number of persons in the population with hypertension is one of the objectives of
Healthy People 2020 (Office of Disease Prevention
and Health Promotion, 2015). Approximately 1 in 3
U.S. adults – about 70 million people – have hypertension; of those, only 52% have their blood pressure
(BP) under control (Farley, Dalal, Mostashari, &
Frieden, 2010; Kung & Xu, 2015). Approximately 1 to
5 out of every 100 children and adolescents also have
hypertension. In adults, BP above 130/80 suggests further monitoring; however, in children normal values
are determined by age, sex, and height. The skill of
the person obtaining the blood pressure measurement
affects accuracy (Battaglia, 2006). The National High
Blood Pressure Education Program (NHBPEP) recommends children age 3 years and older should have a
BP evaluated in a medical setting at least once a year
(NHBPEP, 2004). Additionally, the NHBPEP states
children younger than 3 years should have a BP measurement under the following special circumstances:
history of prematurity, neonatal complications requiring intensive care, congenital heart disease, and treatNURSING ECONOMIC$/July-August 2016/Vol. 34/No. 4
ment with drugs known to raise BP (NHBPEP, 2004).
The strongest risk factor for hypertension in children
and adolescents is being overweight. Finding and
treating hypertension early in young people could
lower their risk for complications during adulthood.
To help clinicians decide whether to screen, it is necessary to know whether early detection actually improves health outcomes. It is also important to consider the potential harms of starting BP medications
and other treatments in young people (Moyer & U.S.
Preventive Services Task Force, 2013).
The role of the ambulatory care nurse is present
throughout a patient’s lifespan; therefore, an important disease correlate, such as hypertension, is vital to
nursing assessment and follow-up care (Start et al.,
2016). Blood pressure is already a topic associated
with nurse-only visits in primary care and specialty
practice settings for adults and children; therefore, it
is an excellent example of a nurse-sensitive measure
of quality.
Ambulatory Care Nurse Screening and Follow-Up
Documentation for Depression. Depression affects up
to 9% of patients and has an associated health care
cost of more than $43 billion in medical care costs
and $17 billion in lost productivity annually. Depression is projected to become the second largest
cause of disability by 2020 (Maurer, 2012). Depression is often not treated adequately. Even when treated appropriately, more than 75% of patients with
depression have recurrent episodes and approximately 30% have residual symptoms (Maurer, 2012).
Depression has been associated with poorer outcomes
in patients with a variety of medical conditions, such
as coronary artery disease, diabetes mellitus, and
stroke (Ciechanowski, Katon, & Russo, 2000; Ford et
al., 1998; Robinson, Bolduc, & Price, 1987). The Centers for Disease Control and Prevention (CDC, 2013)
recognizes the mental health of workers is an area of
increasing concern to organizations, as depression
causes disability, absenteeism, and loss of productivity among working-age adults. The U.S. Preventive
Services Task Force (2009) recommends screening
adolescents and adults for depression in clinical practices that have systems in place to ensure accurate
diagnosis, effective treatment, and follow-up care
(Maurer, 2012).
The NSI TF believes this depression screening
measure is more complex than others and nurse specificity is not cer …
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