The Future of Nursing Leading Change, Advancing Health (2011) / Chapter Skim
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F Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Not Past Demands
F Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Not Past Demands
Pages 375-400
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From page 375... ...
The health reform legislation signed by President Obama on March 23, 2010, and the American Recovery and Reinvestment Act of 2009 which proceeded it, include a range of initiatives that seek to redesign the organization, financing, and delivery of health care. A number of these programs -- for example, primary care medical homes and accountable care organizations (ACOs)
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From page 376... ...
An examination of the health reform legislation and other related policy initiatives reveals a number of programs and provisions that call for reorganization of health care services and the workforce responsible for delivering them. Their implementation could have a significant effect on the future roles of and requirements for RNs.
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From page 377... ...
. Several programs and initiatives included in the health reform legislation involve interdisciplinary and cross-setting care coordination and care management services of RNs.
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From page 378... ...
. A fully functional PCMH is founded on patient and caregiver engagement in care that meets patient preferences; information and education that promotes self-management; care coordination that monitors, reviews, and follows up on all services needed and provided across settings; secure transitions across health care settings; and effective information flow across all providers and services to assure integrated care delivery (Davis et al., 2005; Gerteis et al., 1993)
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From page 379... ...
to undertake a demonstration program to test the effectiveness of PCMH models for Medicare enrollees and the capacity to achieve both quality outcomes and lower health care spending through such approaches to organize primary care. Provisions in the health reform legislation complement Medicare's demonstration program, testing different PCMH models and creating a new CMS Innovation Center to support testing new approaches to organizing, delivering and paying for health care services (Chokshi, 2009)
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From page 380... ...
The Coleman model employs advanced practice nurses as "transition coaches" to manage chronically ill patients and their care needs as they transition between settings and to encourage these patients and their caregivers to assume more active roles in managing their care. The Naylor model targets complex chronically ill patients -- those with multiple chronic illnesses and other complicating conditions -- and uses specially trained transitional care nurses to provide, manage, and coordinate the full complement of clinical care and transitional care services during, between, and after the hospital stay.
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From page 381... ...
The care management and coordination strategies adopted by ACOs and other types of integrated delivery systems require an RN workforce that is linked to the patient, can readily transition with the patient across time and care settings and is ultimately accountable for outcomes that transcend time and place. RNs working in this context would be employed by the ACO, one of its practices or contracting care coordination organizations and would be responsible for care management for the most complexly ill patients in the group and for their care transitions.
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From page 382... ...
Other services and settings offering access to primary care and preventive health services and receiving enhanced support from the health reform legislation and consequently will place additional demand on RNs include workplace wellness programs, home-based primary care (e.g., Independence at Home program) , nurse home visitation services, nurse-managed health centers, and community health teams.
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From page 383... ...
2008. Special report on the characteristics of the registered nurse population in Pennsylvania.
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From page 384... ...
a redesign of the roles and skill mix of the health care workforce and the ways in which multidisciplinary teams will work with one another; (3) new paradigms for how time and place will influence the delivery of care; and (4)
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From page 385... ...
Similarly, many types of care previously provided by physicians and other highly trained personnel can be effectively provided by advanced practice and other specialty trained RNs. Furthermore, the performance of these fundamentally restructured teams will be monitored through the use of biometric, psychometric, and other types of process and outcomes "e-indicators" extracted from the HIT infrastructure.
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From page 386... ...
. CHALLENGES AND RECOMMENDATIONS The composition and distribution of the current RN workforce is diverging increasingly from workforce need to support the implementation of health reform and related initiatives.
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From page 387... ...
The education sector has responded to that demand, producing nurses well prepared to deliver acute care services largely in acute care settings, with a shallow skill set and thin distribution in other areas such as ambulatory care, home-based and community-based care, and geriatrics and long-term-care services. If the demand for RNs changes in response to the system changes and incentives embodied in the health reform legislation and related initiatives, what will 1,000 800 RN-to-population ratio 600 400 200 0 1980 1984 1988 1992 1996 2000 2004 2008 Year FIGURE F-1 RN-to-population ratio, 1980−2008.
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From page 388... ...
. Increasing the presence of RNs in settings and positions that will assist the development of care management initiatives will require preparing RNs to direct team-based care management strategies and transitional care from ambulatory care practices, and reassessing the need for a growing share of the nurses to fill staffing vacancies in hospitals.
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From page 389... ...
Payment reform that rewards effective coordination of care over inefficient use of acute inpatient services will demand RNs with skills in care management particularly for the complexly chronically ill, transitional care and community-based services. Payment reform that promotes the creation of medical homes will demand the production of RNs who can provide and direct interdisciplinary teams in the provision of primary care services.
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From page 390... ...
Specifically, there is a shortage of RNs deployed to ambulatory care settings and a shortage of advanced practice nurses delivering primary care services. There is a shortage of RNs trained and working as care managers directing and delivering care coordination for patients in acute and post-acute care systems.
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From page 391... ...
Further challenging these efforts will be incorporating the effects of fully integrated health information support, which available evidence suggests will significantly influence the skill mix needed to deliver health care services. HIT will be a key factor affecting the practice of nursing and medicine over the next generation, and its impact on nursing practice and workforce requirements is still very poorly understood.
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From page 392... ...
The U.S. Department of Health and Human Services should establish a government-wide interagency innovations research collaborative comprising all agencies/departments engaged in health care service delivery and research, with the goal of testing new models to organize and pay for health care services and determining the workforce features critical to achieving desired cost and quality outcomes from these new models.
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From page 393... ...
create a multistakeholder National Workforce Advisory Group responsible for developing op BOX F-2 Processes and Policy Initiatives Producing Health Care Workforce Skill Mix Changes Processes producing role changes that influence skill mix: • Enhancement -- Current role of provider is extended • Substitution -- Provider's role expanded by exchanging tasks with another type of provider • Delegation -- Tasks are moved up or down a "traditional" disciplinary ladder • Innovation -- New domain of practice is created by introducing a new type of provider with a previously untapped scope of practice Policy initiatives producing shifts in roles and skill mix: • Transfer -- Services previously provided in one setting (e.g., hospital) are now provided in another setting (e.g., ambulatory care)
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From page 394... ...
The reorganization of health care service delivery that will accompany many of the innovations included in health reform has potentially profound implications for RNs, whose broad scope of practice places them at the cross section of virtually all health care settings. Redefining roles and responsibilities of health team members that such innovations will entail could significantly affect the skill mix
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From page 395... ...
Delivery system redesign initiatives included in health reform depend upon a set of skills and experiences that nursing education has yet to incorporate demonstrably into its pedagogy. Primary nursing education is still largely located in the acute care domain, with students mastering the care of the acute manifestations of chronic disease rather than care management of complex chronic illness.
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From page 396... ...
For example, Medicare-funded pilot studies and demonstration programs testing programs that rely on nursing-led interventions, such as ACOs or transitional care, should include representatives from nursing education -- its leadership as well as key stakeholders, such as the regulatory bodies that determine the terms and scope of nursing education and practice -- in activities associated with the design, review, implementation, evaluation, and dissemination of these initiatives. In similar form, health professions schools testing models of interprofessional education and other models of teambased care education should include representatives from the clinical directors of medicine and nursing in health systems and other key stakeholders from the clinical practice communities.
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From page 397... ...
2007. Geriatric care management for low-income seniors: A randomized controlled trial.
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From page 398... ...
1982. The registered nurse population: An overview from National Sample Survey of Registered Nurses, November 10.
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From page 399... ...
2002. The registered nurse population, March 2000: Findings from the National Sample Survey of Registered Nurses.
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From page 400... ...
2006. Findings from the March 2004 National Sample Survey of Registered Nurses.
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