Tootsie’s Story, Continued: A Family Wonders Whether Nurse-Led Care Coordination Might Have Prolonged a Life
Jennifer Bellot, PhD, RN, MHSA, is an assistant professor at Thomas Jefferson University and a Robert Wood Johnson Foundation Nurse Faculty Scholar. Yesterday, she blogged about the death of her beloved grandmother, Tootsie, due to complications from medical error that began with an overdose of Synthroid. This is Part Two of Bellot’s blog post.
In 2010, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) joined resources and released The Future of Nursing: Leading Change, Advancing Health. This landmark report included many recommendations, and a full-scale Campaign for Action is in place that will transform nursing for years to come. Among the many themes advocated in this report is the tenet that nurses should be the very core of reinventing the American health care system. The report encourages the health care system to lean, and lean heavily, upon the skill set and resources of nurses to facilitate access to higher quality care at a lower cost.
At present, we have a health care system that is technology and intervention heavy when we know our population demographics are rapidly changing and technological intervention is not always the right answer. We have a growing need for a system that instead focuses on addressing chronic disease management, prevention and wellness care. Nurses are well positioned to support a system with these foci, managing care of the older adult in the community before inpatient care becomes necessary. Specifically in the outpatient setting, nurse coordinated care that is, by definition, proactive, holistic and comprehensive will help shift the focus of care from acute and episodic to chronic and preventive.
The advanced practice nurse is especially positioned to coordinate the complex care of the older adult via nurse-managed health clinics and the patient-centered medical home model. To do so effectively, however, nurses must be compensated equitably for the care management skills they provide. At present, although nurse-managed health clinics are now eligible for patient-centered medical home designation, there is not equitable reimbursement between physicians and advanced practice nurses for providing the same level of care under this model. Further, there are 50 different scopes of practice in 50 different states for advanced practice nurses in the United States, providing inconsistent privileges and erecting barriers to everything from prescribing effective analgesia, ordering appropriate durable medical equipment, and ensuring that home care services are in place and appropriate.
It cannot be overemphasized that this is not a political issue. No one is trying to intrude on the scope of practice of physicians, therapists, social workers, or other members of the health care team. Rather, the RWJF/IOM report seeks to emphasize the relative merits and traditional education and training of the nurse to support a system of care coordination, effective communication, seamless transitions, chronic care management, disease prevention, and maintenance of wellness.
Could nurse-led care coordination have changed Tootsie’s narrative? We will never know. But, what would have happened if her primary care provider had better communication with the pharmacy, eliminating the initial overdose? What if her care were managed by a nurse practitioner who was knowledgeable of her outpatient history and was able to follow her care once she was hospitalized, be an active part of the care team, and ensure that the acute care team was fully aware of her underlying health status?
Would Tootsie have been discharged to her apartment if a nurse practitioner had assessed that it was not safe, nor practical, and that appropriate home care services were not arranged prior to discharge? Would a robust communication system have eliminated missed opportunities, decreased the potential for medical error and, in one important instance, allowed prompt treatment of a urinary tract infection in order to avoid readmission?
After scouring her medical records, one thing is clear: Tootsie’s course was hardly unique. Frail elders and chronic disease walk hand in hand. What we can do to improve quality and increase thoughtfulness to the care we provide is to begin using our nursing resources to their fullest extent. We would be wise to use the preventative, holistic and wellness focus that nurses are trained for and place them where patients are most vulnerable: discharge, home, outpatient management, and readmission. Then, perhaps most critically, give nurses the tools, resources and scope of practice needed to manage frail elders effectively.
It’s not about politics; it’s about providing better care. I have no doubt, in the battle between stringent policy and better health outcomes, Tootsie would urge us to let her nurses take care.