A number of initiatives founded by nurses have saved countless lives and millions of dollars.
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| David Ollier Weber |
We all know what nurses do.
Well, to be sure, some fly in helicopters. Some deliver babies. Some sit at the head of an operating table administering anesthesia. Some oversee the front-line primary care of patients at clinics and neighborhood medical offices. Some teach in colleges and universities. Some serve as senior executives of hospitals and medical enterprises.
Mostly, though, we think of nurses as tending the sniffles and skinned knees of schoolchildren, staffing physician practices, bustling among the elderly in nursing homes and solicitously bending over patients in hospital ICUs and medical units. Those really are the settings in which the vast majority of registered nurses work. They pop into rooms to deliver medications, change IVs, re-bandage wounds, check vital signs and, in the process, maybe fluff a pillow, empty a bedpan and murmur an encouraging word. They walk on soft soles. They hunch in the dim light of nursing stations, carefully charting. They speak in low, soothing tones.
Nurses are consistently ranked by respondents to the Gallup Poll as the most trusted, most honest and ethical of American workers.
That’s no small point of pride to Pat Ford-Roegner, M.S.W., R.N. But as president of the American Academy of Nursing (AAN), she wants the world to know that her profession has more to contribute than stereotypical, susurrous bedside TLC.
At a time when the U.S. health care system is displaying all the signs of septic shock—“inaccessible to many, expensive for most and fragmented for all,” the AAN summarizes—Ford-Roegner’s organization has launched a campaign, Raise the Voice, to bring nursing into deliberations over how to resuscitate the failing patient.
Cases in Point
In fact, nurses can already point to dozens of remarkably effective initiatives they’ve spearheaded to improve the quality and, concomitantly, the scope, equity, efficiency and economy of American health care. Consider these nurse-driven programs and their results:
Evercare. Introduced in 1987 by two Minnesota nurse practitioners, Jeannine Bayard and RuthAnn Jacobson, the Evercare model today serves more than 120,000 people in 35 states through Medicaid, Medicare and private-pay health plans. Evercare was designed to overcome the fragmentation of resources that drive up medical costs and contribute to poor outcomes for people with long-term or advanced illnesses, the elderly and those with disabilities.
The Evercare model places a nurse practitioner or care manager at the center of an integrated team that includes the enrollee’s physicians, family members and nursing home staff or representatives from community service agencies. Working with the enrollee and the care team to develop a personalized plan, the nurse practitioner or care manager coordinates multiple services, facilitates communication among the various physicians, institutions, patients and their families, and helps ensure effective integration of treatments.
Where Evercare has been adopted, it has reduced hospitalizations for nursing home residents by 45 percent and cut emergency room trips by 50 percent. The state of Texas estimated that it saved some $123 million in Harris County alone between February 2000 and January 2002 by implementing this nurse-inspired innovation.
Nurse-Family Partnership. Headquartered in Denver, the Nurse-Family Partnership serves first-time mothers in low-income families in more than 280 counties in 23 states across the nation. Under the program, a registered nurse provides in-home advice and care to primiparous women through frequent visits—14 during pregnancy, 28 during infancy and 22 during the toddler stage—over a two-and-a-half-year period.
The Nurse-Family Partnership has shown dramatic results. Studies indicate pregnancy-induced hypertension among participating women is reduced by 35 percent, preterm deliveries for women who smoke are reduced by 79 percent, child abuse and neglect is reduced by 50 percent, emergency room visits are reduced by 35 percent overall and by 56 percent for accidents and poisoning, and language delays in children at 21 months of age are down 50 percent. Indeed, the Washington State Institute for Public Policy found that the program had the highest return on investment among all home visiting and child welfare programs evaluated, with a net benefit to society of $17,180 (in 2003 dollars) per family served—$2.88 saved for every dollar invested.
Family Health and Birth Center. Founded by Ruth Watson Lubic, Ed.D., R.N., and housed in a former supermarket in a low-income section of Washington, D.C., this exemplary facility provides modern birthing, comprehensive women’s and children’s health care, social support, and early childhood development services in a nurse-driven setting.
Backed by hospital obstetrical and gynecological consultants, nurse midwives at the Family Health and Birth Center delivered 150 babies in 2006, 25 percent at the facility. After less than six years of operation, the program in 2005 recorded a 9 percent preterm birthrate as compared with 14.2 percent for the District of Columbia overall, a low birth weight incidence of 7 percent compared with 14.6 percent, and a Caesarean section rate of 15.3 percent versus 29 percent. Those achievements in a medically underserved community translated to reduced costs for the District of Columbia’s health care system of at least $1.15 million—more than the center’s total annual operating budget.
11th Street Family Health Services, Drexel University. This nurse-managed center, founded in 1998, brings a full range of primary care, dental, behavioral health, health promotion, and disease prevention services to residents of four public housing developments and their surrounding urban community in Philadelphia—where 57 percent of patients are covered by the state Medicaid plan and 33 percent are uninsured.
No one who shows up at 11th Street is turned away. In 2005-06, more than 19,000 visits were recorded. Not only does the center provide one-stop shopping for health concerns to its largely African-American clients, it boasts a fitness center, a teaching kitchen, and weekly distribution of fresh fruits and vegetables.
Almost 8,000 primary care visits took place in 2006, with significant documented benefits to patients. Hemoglobin A1C levels among 11th Street’s diabetic patients were reduced by 20 percent; almost 70 percent of hypertensive program clients now have their blood pressure under control (for African-Americans that far exceeds the nationwide 2010 goal of 50 percent, from a 2000 national baseline of 19 percent); immunization rates for adults were increased by 14 percent; and sharp improvements were recorded in the number of low birth-weight babies, depression rates in vulnerable adults with chronic illness and breast cancer screening rates.
APN Transitional Care Model. Poor hospital discharge planning and follow-up of elderly patients frequently results in costly and debilitating readmissions that could have been prevented. Aetna and Kaiser Permanente are now testing a model developed at the University of Pennsylvania School of Nursing under which advanced practice nurses (APNs, all of whom have master’s degrees) establish a relationship with patients and their families soon after hospital admission; design the discharge plan in collaboration with the patient, the patient’s physician and family members; and implement the plan in the patient’s home following discharge, substituting for traditional skilled nursing follow-up.
Three clinical trials funded by the National Institute of Nursing Research confirmed that the APN Transitional Care Model improves quality and substantially decreases health care costs. Compared with standard care there are longer intervals before initial rehospitalizations, fewer rehospitalizations overall, shorter hospital stays and greater patient satisfaction. In a four-year trial with a group of elderly patients hospitalized for heart failure, the APN Care Model cut inpatient costs by more than $500,000 compared with a group who received standard care—for average savings of approximately $5,000 per Medicare patient.
Edge Runners
Those are just a handful of 35 thoroughly documented innovations—all readily replicable and adaptable—designed by nurses and outlined on the AAN Web site. Each was formulated by what the organization lauds as “edge runners”—nurses whose ability to think outside conventional boxes spurred major improvements in local, regional and even national health care delivery. (Each profile also includes the telephone number and e-mail address of a contact person for more information.)
Funded by the Robert Wood Johnson Foundation, the Raise the Voice campaign kicked off in November 2006 to “highlight nursing’s leadership in devising practical solutions” to health care’s systemic problems, declares Ford-Roegner. Donna Shalala, president of the University of Miami and former Secretary of Health & Human Services, chairs its prestigious national advisory board.
Health care reform was a major issue in the 2008 presidential election; it will clearly command the attention of legislators, physician organizations, insurers, purchasers, pharmaceutical and medical technology companies, hospital executives, academics, and consumer groups throughout the country in the months ahead.
“Nurses have ideas and need to be engaged at the highest level of discussion,” emphasizes Ford-Roegner.
After all, whether it’s you who’s sick or it’s your health care system, who are you going to call?
You could do worse than to start with the advice of a nurse.
David Ollier Weber is principal of The Kila Springs Group in Placerville, Calif. He is also a regular contributor to H&HN Weekly.
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