Category Archives: Patient-centered care
As we head into 2012, the Human Capital Blog asked Robert Wood Johnson Foundation (RWJF) staff, program directors, scholars and grantees to share their New Year’s resolutions for our health care system, and what they think should be the priorities for action in the New Year. This post is by Diana J. Mason, PhD, RN, FAAN, Rudin Professor of Nursing and Co-Director, Center for Health, Media & Policy, Hunter College, City University of New York; Strategic Adviser, Future of Nursing: Campaign for Action; co-editor, “The Nursing Profession: Development, Challenges, Opportunities,” RWJF Health Policy Book Series.
While I was editor-in-chief of the American Journal of Nursing, I and some of the editorial staff noticed that most of the manuscripts we received for our narrative column, Reflections, were about death and dying. We begged people to submit columns on other topics, lest Reflections become As I Lay Dying. But I shouldn't have been surprised.
As a nurse and daughter of a man who died at 58 from metastatic cancer, I have cared for many dying people and have been privileged to be with some at the moment of their deaths. I've had patients who told me that they were going to die that night—and they did. I've seen an 85-year-old woman kept alive on a respirator with an open abdominal wound for four weeks before she became septic and died, despite her stated wishes to not have such extraordinary measures. Caring for my father during the last month of his life was the most precious gift I was able to give to him—and to myself. Yet, I had to fight with the health care system to ensure that he was adequately medicated when hospitalized or to be able to remain with him during an emergency room procedure. I fought to take him home so he could die there, as he wished, with love and comfort care.
These experiences imprint themselves indelibly on our memories and our souls. They can be rich and profoundly move us to confronting the realities of our own life and inevitable death. Or they can make us witnesses to torture and inhumane treatment of the dying, and shake our core beliefs about how a rational, caring society behaves.
The U.S. Department of Health and Human Services (HHS) last week announced the launch of the Comprehensive Primary Care Initiative, to improve the quality of care for Medicare and other patients. The voluntary program, which will begin as a demonstrative model in five to seven markets, encourages primary care doctors and nurses to work with specialists and other health care providers to better coordinate patients’ care.
Primary care providers will receive support and resources to help develop personalized care plans for patients with complex health care needs, offer 24-hour access to care and health information, deliver preventive care, and engage patients and their families in their own care. Practices that do that so will receive an additional monthly fee from Medicare in markets where private insurers agree to do the same. The increased focus on prevention and care coordination is expected to results in savings that will later be shared with primary care practices that participate.
“This collaborative approach has the potential to strengthen the primary care system for all Americans and reduce health care costs by using resources more wisely and preventing disease before it happens,” HHS said in a release.
"The American College of Physicians (ACP) believes that the Comprehensive Primary Care Initiative offers enormous potential to promote the kind of personalized and coordinated care that patients seek and that physicians want to deliver," said Steven Weinberger, MD, FACP, executive vice president and CEO of ACP. "It will provide primary care physicians with the support needed to work hand-in-hand with patients toward a shared goal of ensuring high quality care while making the most efficient use of health care resources… Internal medicine physicians know from their personal experiences that when care is coordinated and centered on patients’ needs and expectations, through a primary care practice that uses proven 'best practices' and is accountable for the results, outcomes are better and costs are lower."
I became a family nurse practitioner after practicing for many years in home health and hospice. When you make house calls, you are a guest in a patient’s home, and “patient-centered care” is what you do. Patients and their caregivers benefit when the advanced practice registered nurse who is assessing the patient has the authority to prescribe needed pain medications, admit patients to hospitals and other facilities, and order needed home health or hospice services.
The Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, recommends removing barriers to care and allowing advance practice registered nurses to practice to the full extent of their education and training. Barriers to care such as requiring physicians to countersign documents add additional steps, increase health care costs, and delay needed care. The IOM report recommends amending the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health services and for admission to hospice and skilled nursing facilities.
All patients, especially chronically ill patients and their family caregivers, need every member of the health care team to communicate and collaborate to provide high quality coordinated care. Interprofessional collaboration is a partnership that starts with the patient and includes all involved health care providers working together to deliver patient and family centered care. Nurse practitioners and other advanced practice registered nurses are educated and trained to collaborate with and refer to physicians and other health care professionals. But collaboration can have a negative connotation. Restrictive collaboration laws and regulations that require physicians to supervise or sign-off on care provided by nurse practitioners and other advanced practice registered nurses are duplicative and costly barriers to patient and family centered care.
When I moved to Maryland seven years ago, I had to find a job with a physician who was willing to sign a 16-page “collaborative agreement” before I could be licensed to practice. Two years later I changed jobs and joined a nurse practitioner-owned primary care practice in the District of Columbia. My education and training did not change when I changed practice venues from Maryland to DC, but in DC “collaboration agreements” have never been required.