Increasingly, hospitals rely on RNs to fill the primary care gap and meet the many new health care imperatives
The Mayo Clinic in Rochester, Minn., is no stranger to repeat patient visits. But providers were stunned when they realized one individual had 76 encounters in 2010. "According to the care coordinator, the patient came to urgent care, the emergency department, the primary care office and the hospital sometimes as often as two to three times a week," says Diane Twedell, vice president and chief nursing officer for Mayo's Austin Medical Center. "So, we took the needed steps and got those 76 visits in 2010 down to just four in 2011."
Curbing this excessive health care system use and ensuring that the patient received the appropriate care called for a simple solution, Twedell says: getting the care coordinator — in this case, a nurse — more involved at every step of the patient's care. The nurse followed up with the patient after each appointment, designed different care plans and facilitated transitions between clinical settings. The result: health care that maximized quality and minimized cost.
Ultimately, that's the intent of the accountable care model. Many industry leaders consider expanding the role of nurses and using their skills to the utmost essential in giving patients more coordinated, team-based care. If nurses have more responsibility over care management and a louder voice in designing workflow, not only will public health improve, but the health system also will be leaner and more effective, they contend.
Expectations and pressure are high as the field faces the impending influx of more than 30 million people with expanded coverage under health reform. However, there are still many questions about what responsibilities nurses should assume and how hospitals can best assess their own needs. There are also concerns about whether enough nurses will be available in the coming years to meet the needs of an aging and increasingly complex patient population.
In every clinical care environment — hospitals, nursing homes, ambulatory care centers — nurses nearly always have the closest relationship with patients. They are the front-line providers who monitor and meet patient needs; they are the information conduit from patient to physician; and they are the dogged patient advocate who lobbies for both patient and family.
But, as a group, nurses often neglect discussing their contributions to high-quality patient care and overlook opportunities to offer input on workflow design, says Pam Thompson, R.N., chief executive officer of the American Organization of Nurse Executives, an American Hospital Association subsidiary group. Effecting change will require nurses to be proactive.
"Nurses have pretty much always been invisible, but we must ask to be included in conversations about care management," Thompson says. "We know how care is supposed to be delivered. From working across the continuum, to smoothing handoffs, to working to prevent readmissions, nurses cannot be silent. We must speak up and say, 'We can do this.'"
The Future of Nursing: Leading Change, Advancing Health, a report published by the Institute of Medicine in October 2010, highlighted nurses' ability to reduce gaps in care and stressed the imperative that they do so. According to the report committee, nurses are ready to stretch their wings as primary care providers to increase access to services and organize complex care plans for wide ranges of patients. They often prevent medication errors, reduce infection rates and facilitate patient transitions from hospital to home.
If allowed to work to their full potential, nurses can help hospital administrators strike the right balance between providing the best possible clinical care and controlling costs, says Patricia Hines, R.N., clinical and operations expert and vice president for the Camden Group, a health care consulting firm. "We must try to create an environment that optimizes the role of the professional nurse," Hines says. "They can engage in value-based purchasing for the client; they can spend time on patient education, prepare for care coordination and increase their interaction with primary care providers."
In many cases, nurses already are serving as care coordinators, health coaches, disease managers and community liaisons. Others conduct research at the bedside and analyze the data. But for nurses to assume these roles officially on a broad scale, a number of things need to happen, says American Nurses Association President Karen Daley, R.N.
The biggest is expanding the scope of nursing practice, she says. "The current hierarchy and archaic, traditional way of doing business within a lot of hospital environments impedes nurses' ability to provide care," Daley asserts. "Nurses must own their power and the potential of their practice."
Not everyone agrees. The physician-led team is a tested strategy, according to the American Medical Association, and changing tactics when health care is facing a significant major influx of patients could impact all providers' abilities to give patients the best, most cost-effective care.
"With seven years or more of postgraduate education and 10,000 hours of clinical experience, a physician is uniquely qualified to lead the health care team," says AMA President Peter W. Carmel, M.D. "Physicians, physician assistants and nurses have long worked together to meet patient needs for a reason — the physician-led team approach to care works. Patients win when each member of the health care team plays the role he or she is educated and trained to play."
Scope of practice is a controversial legislative issue. Most states restrict the services nurses, including nurse anesthetists and nurse practitioners, can provide without supervision. Only 14 states allow NPs to diagnose illness and prescribe medication without physician oversight, but the battle is building nationwide.
As health care shifts toward a more team-based approach, many nurses already are moving into roles that build upon their previous responsibilities, such as developing greater care coordination and conducting population analyses.
As clinical leaders, nurses can have a significant impact through discharge planning, says Marilyn Chow, R.N., Kaiser Permanente's vice president of national patient care services. They are uniquely qualified to recognize and provide tailored guidance for patients at risk for negative outcomes or a readmission. "At discharge, nurses can improve a patient's outcomes by going through their medications, discussing any side effects, and asking if they have any questions," she says. "Being proactive is very important."
In many cases, Chow says, NPs serve as care coordinators, guaranteeing continuity under the collaborative model. As the primary provider, he or she can follow patients easily cross settings to monitor their progress and needs, as well as catch problems early.
NPs with Harvard Vanguard Medical Associates proved that point when they launched a program for congestive heart failure patients, many of whom received conflicting advice from their various physicians. Each patient is assigned an NP who works with specialists to design a single care plan. Within a year, the program slashed emergency department visits by 92 percent for that group of patients.
Nurses also can improve care in a patient's home. Pittsburgh Regional Health Initiative's CEO Harold Miller says the organization saw a 40 percent drop in readmissions for advanced lung disease patients when nurses began conducting home visits.
A nurse's first-hand knowledge of a patient's condition also can lead to discussions with colleagues about disease management for complex patients, says Patty Jones, R.N., a health care management consultant with independent actuarial firm Milliman. Floor nurses, she says, can expand their practice scope by providing follow-up care through home visits.
Maintaining these relationships bolsters nurses' abilities to manage the needs of certain groups proactively, such as patients living with diabetes or children with asthma, she says. Through analysis of patient data, nurses can create interventions that potentially improve the group's overall health.
Doing so makes nurses cost managers, as well. Not only do they augment the patient experience, they also positively impact population health. As a result, hospitals often see a drop in their patient per capita care costs, Hines says.
Broader nurse activity saved Wisconsin-based Marshfield Clinic $118 million during a five-year project funded by the Centers for Medicare & Medicaid Services. The clinic beefed-up its 24-hour nurse hotline to serve both adult and pediatric patients and added physician-directed, nurse-managed heart failure, high cholesterol and anticoagulation therapy programs.
A similar hotline program at the Mayo Clinic allowed nurses to provide more than 11,000 treatment protocols over the phone, including for urinary tract infection and sinusitis, within 18 months, freeing up office visits for patients with more acute needs, says Stephanie Witwer, R.N., a primary care nurse administrator with the clinic.
To fulfill their roles under an ACO or other coordinated care model, nurses will need additional skills in many areas — from technology to evidence-based research. Enhanced education will be the foundation of it all.
The IOM report called for at least 80 percent of practicing nurses to have a bachelor's degree by 2020, and industry experts are supportive. "Nurses with a BSN have the skill set and critical-thinking abilities needed for evidence-based practice," Hines says. "They have more exposure to collaboration and team-building and readily can create a culture of quality and safety."
Many hospitals already have begun moving toward an all-BSN workforce. In October 2010, shortly before the IOM issued its recommendation, North Shore–Long Island Jewish Health System in New York mandated that all newly hired nurses hold a BSN, says Elaine Smith, R.N., vice president for system nursing education.
The Future of Nursing report bolstered our conviction that it's necessary for nurses to be better educated," Smith says. "As we look to change how the health care system is designed and better manage patients across transitions of care, our nurses need to have the skills that only can be acquired with higher education."
Although the initiative is still too young to determine what, if any, improvements or benefits an all-BSN workforce brings to patient care, Smith says response to the move has been enthusiastic. There are, however, steps hospitals must consider to facilitate baccalaureate education for staff nurses who desire it. Institutions should negotiate with nursing schools to secure employee tuition discounts, partner with schools to provide classes on hospital grounds, and determine what type of tuition reimbursement to offer.
Achieving a higher level of education will expose more nurses to one of the most important aspects of health care reform: the push toward greater use of health information technology. For example, nurses who are proficient with telemedicine can monitor their patients easily in their homes, keeping tabs on any daily activity or medication needs.
To date, electronic health records are the most significant IT investment for most health care settings. It is clear CMS expects all clinical care environments to achieve HIT proficiency, and nurses must be among the most enthusiastic adopters, Daley says.
"Nurses need the most in-depth knowledge and hands-on experience with health information technology," she says. "Many nurses already are skilled far beyond basic competencies. They have a comfort level with this technology that can help them communicate with other providers and can allow them to make the most of their role in coordinated care."
But it's not enough for nurses to simply use an EHR, says Milliman's Jones. Hospitals must include nurses from the beginning of the IT planning process and request their feedback about what works and what does not throughout the selection and implementation process.
Community care settings offer the biggest opportunity for nurses to use technology to improve the quality of care, Jones says. The data nurses gather from the older and underserved populations who receive health care in the community can be used to improve patient care processes within hospitals.
Community-acquired information also can be used to support evidence-based research, says the ANA's Daley. Armed with outcomes data, nurses can present hospital administrators with process changes to improve both workflow and patient care. For example, nurses with the public-private Community Care of North Carolina analyzed claims data, including repeat emergency department visits and chronic-condition diagnoses, to pinpoint patients who likely would benefit most from case management. According to a 2008 Annals of Family Medicine article, by tracking utilization and communicating with other managers, CCNC nurses have saved the state about $160 million annually.
Bringing such an impact to widespread fruition, however, often means nurses must improve their communication channels with physicians and hone their leadership skills, Daley says.
According to Kaiser Permanente's Chow, any skill improvements or systems changes should be achieved with a singular goal in mind: improving transitions not only between shifts but also between care environments.
"Everything we do and put in place as nurses should be done to strengthen handoffs, especially among inpatient, outpatient and home care settings," Chow says. "We are always motivated to make situations better for our patients, and the best way to do that is to ask for their perspectives."
Kaiser Permanente nurses routinely ask patients about any fears or questions they have regarding their care plan, how involved they wish to be in their health care, and what, if any, additional information would help medical staff provide better care, she says.
While most experts agree patients benefit when nurses are more active in designing care plans or working in the community, for many clinical settings, putting nurses in those roles will take time. Health care has a long-standing perception of nurses as providers who implement physician orders and have little impact on a patient's well-being. For systemwide reform to succeed, that view must change, Daley says.
Pittburgh Regional Health Initiative's Miller agrees, noting that the current silo structure can thwart efforts to expand teamwork.
But hospitals must be ready for the change, says HSS's Goldberg. The first step toward broader nurse activities is to ensure that the facility's executive committee is on board with the idea.
Secondly, the CNO must meet with all senior leadership to conduct a gap analysis and choose external benchmarks by which they can measure their success against other organizations. Goldberg suggested using patient satisfaction scores or data from the National Database of Nursing Quality Indicators.
"This is the time for the hospital's administrators to take stock of what they don't have, what they need to do to get there," she says. "Then, they can lay out a two- to three-year plan on how to accomplish it all."
During these conversations, Jones says, hospitals should assess whether their nursing staffs have the necessary skills to put any new policies into place. Administrators should look for nurses who are experienced in teamwork, familiar with evidence-based research, fluent in HIT, and armed with the knowledge and skills that will lead to quality improvement.
Hospitals also should create a long-term succession plan. Although the current weak economy has pushed many people to either continue practicing or enter nursing as a second career, the much-publicized nursing shortage will return, Hines warns. "It would be appropriate for facilities to identify their next tier of nurse leaders now and pair them with a mentor from a group that likely will leave the workforce once the economy settles," she says. "This way, they can avoid having a nurse leader gap."
Accountable care will change how and by whom services are delivered. Perhaps the greatest challenge for nurses, Jones says, will be to relinquish responsibility. Many nurses accustomed to carrying heavy workloads may have difficulty delegating tasks to other providers.
But reassigning the jobs others can do will free nurses to step into positions that will affect systems change and directly impact patients more readily.
"Nurses have so much to contribute to patient care by means of quality and efficiency," Daley says. "We haven't begun to tap even a small percentage of their potential within health care."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
The Future of Nursing: Leading Change, Advancing Health was published by the Institute of Medicine in 2010 based on a two-year initiative with the Robert Wood Johnson Foundation to "assess and transform the nursing profession." The report points to barriers that prevent nurses "from being able to respond effectively to rapidly changing health care settings." It calls for nurses to be able to practice to the "full extent of their education and training," receive additional training and education, and be full partners in clinical teams. It also calls for advances in workforce planning and policy making. Go to www.iom.edu to download a copy of the report.
• Patients trust nurses
Hospitals should take advantage of the comfort level patients have with nurses. Surveys have shown that patients are less intimidated by nurses than by physicians and are less apt to withhold information about how they're feeling no matter how minor the patient considers the complaint to be. A recent Gallup poll found that the American public trusts nursing more than any of the other 100-plus professions included.
• Equal partners
As team-based care replaces the traditional physician-dominated approach, nurses should be encouraged to take a more active and vocal role.
• Continuum keystones
Value-based reimbursement is prompting hospitals to coordinate care with a patient's other providers, including in the post-acute care setting. Nurses can help patients understand their discharge instructions and then follow up by phone and in person to make sure they are following those instructions and will not need to be readmitted unnecessarily.
• The need to know
Hospitals should help nurses acquire the additional education and skills they need to handle their expanded responsibilities. That means working with nursing schools to make sure they have robust baccalaureate and advanced-degree programs and to provide nurses with adequate training in information technology.
• Please don't leave
The recession discouraged nurses from leaving the profession, but most experts warn that the nursing shortage will return as large numbers of RNs hit retirement age. Hospitals should encourage older nurses to remain on the job, using a variety of strategies such as flexible schedules and less strenuous tasks.
This article first appeared in the March 2012 issue of H&HN magazine.