Arizona nursing connections: Conclusion of AzNA's Practice Grant

Arizona Nurse, Jul 2001

What key events marked the funding progress of the project?

The CNOs began as a three-year project expected to terminate at the end of 1996. Since 1996, the CNO demonstration has been extended three times. In 1996, HCFA granted a one-year extension to continue the evaluation of quality and cost outcomes. Throughout 1997, the four CNOs worked closely with the ANA and Congressional representatives from each of the four states to extend the CNOs until December 1999. Another extension was sought and received in 1999.

However, this last extension included a provision to significantly reduce the payment to the CNOs. As a result, the sponsoring organization of two of the CNOs made the decision to withdraw from the demonstration. The Arizona CNO at Carondelet Health Care in Tucson closed in September 2000 and the Minnesota CNO closed in November 2000. The CNOs in New York and Illinois currently remain in operation.

What are the major accomplishments of the project?

The CNOs represent the first time nurses have led the redesign of Medicare services. In the course of six years, more that 10,000 older adults, all Medicare members, chose to join the CNOs and trusted that nurses would serve them well. The vocal support of these 10,000 members influenced Congress to continue the CNO demonstration over and over again. In the four CNOs, nurses tested and revised new ways to coordinate and deliver community-based services and did so under a risk-based capitated payment model and an experimental study design. The financial and political challenges of surviving were significant and the fact that all four of the CNOs thrived for six and a half years is a major accomplishment for all nurses.

Success with the CNO model required the integration of clinical innovation, marketing and management expertise, and a clear understanding of the outcome expectations of the demonstration. Each of the four CNOs experimented with new nursing care delivery systems that anticipated and led the design of what is now considered state-of-the-art case management and disease management systems. The CNOs included nurse case management for high-risk older adults, nurse partners for health promotion and disease prevention services, automated risk assessment of all members, and evidence-based chronic illness guidelines.

Two of the CNOs, including Arizona's CNO, were recognized as "best practice" sites for care coordination in several national studies of best practices. Many of the features of the CNO model were integrated into the design of the soon-to-be implemented Medicare demonstration on care coordination.

What insights did you gain that you might share with Arizona nurses?

Nurses bring a unique and critically important perspective to the design, implementation and evaluation of Medicare services. Our experience with the CNO over six and a half exhilarating and turbulent years emphasized over and over that nurses can and must play a major role in influencing the shape of Medicare for the future. Participating in Medicare reform at the policy level is not easy. However, the CNO experience clearly demonstrates that nurses have important and innovative ideas to enhance clinical delivery of services, assess risk- in a growing elderly population, and to create a more coherent and caring health care system for older adults.