Many of the most prominent participants in the debate over health care reform have promised—or warned—that reform would spark a revolution in the nation's health care system. While the health reform law will change much, the truth is that many parts of the system have been evolving for quite some time, and the changes are already making their mark.
In the area of primary care, economic and demographic pressures have driven innovation. Many such breakthroughs focus on the roles of nurses, many of whom are leading an evolution in the delivery of primary care. Nurse practitioners (NPs) and certified nurse midwives (CNMs), for example, make up a growing portion of the primary care workforce. Meanwhile, RNs and licensed practical nurses (LPNs) are increasingly tracking patients to make sure they get the care they need. In addition, nurses at several levels are managing chronic conditions and coordinating care transitions.
Such evolutionary changes are the subject of the latest installment in the Charting Nursing's Future (CNF) series of policy briefs from the Robert Wood Johnson Foundation (RWJF). It explores the policies that support this evolution, and looks at several innovative models that provide patient-centered, coordinated, and cost-effective care by taking advantage of nursing’s strengths.
“Given the current trends in physician-based primary care, the development of a robust cadre of advanced-practice primary care nurses (and physician’s assistants) should become a major priority. … [It] can be achieved at lower cost and in a shorter timeframe than a comparable increase in the number of primary care physicians. … [Such an increase] might actually contribute to bending the health care inflation curve.”
—The Heritage Foundation, Not Enough Doctors? Too Many? Why States, Not Washington, Must Solve the Problem, by Roger E. Meyer, MD, 2010.
The Institute of Medicine's landmark report, The Future of Nursing: Leading Change, Advancing Health, both highlighted and encouraged the transformation in nurses' roles. It notes that, as the largest and most flexible component of the health care workforce, nurses are “poised to help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of patients, to fulfill their potential as primary care providers to the full extent of their education and training, and to enable the full economic value of their contributions across practice settings to be realized."
Indeed, as the CNF brief observes, NPs are the fastest-growing group of primary care providers, with NP students who plan to enter primary care graduating at three times the rate of their medical student counterparts. Moreover, NPs are more likely to practice in remote and rural areas where physicians are sometimes in short supply.
The brief spotlights a number of innovative models that "redefine nursing roles to extend access, improve care, and contain costs. These models emphasize the care coordination at which nurses excel. They employ interprofessional teams that share responsibility for health outcomes. They exploit information technology to enhance patient communication, track care, and improve clinical decision-making. They change the way care is paid for, and they allow nurses, physicians, and others to practice to the full extent of their knowledge and skills."
Among the initiatives highlighted in the brief are programs in Minnesota, Pennsylvania, and Vermont, as well as a national program implemented by the U.S. Department of Veterans Affairs.
Under a newly installed program at Minnesota-based HealthPartners, a large nonprofit health care organization, nurses are now taking a lead role in primary care. The organization hires NPs, physicians and physician assistants as primary care providers, and also relies on NPs to diagnose and treat some patients via the Internet. Meanwhile, RNs and licensed practical nurses (LPNs) collaborate with these other professionals to anticipate patient needs and make sure they have the supports in place to implement care plans successfully.
According to the CNF brief, HealthPartners nurses review electronic health records and order lab work prior to patient visits. They also coordinate post-visit and between-visit care, including transitional care following hospitalization. RNs assess ongoing concerns prior to visits with primary care providers and follow up to ensure that patients understand and implement their care plans.
The approach has helped HealthPartners provide a standard of care that exceeds state averages as measured by specific quality measures, at a cost 10 percent lower than the state average.
In 2007, in response to the high cost of caring for patients with chronic conditions and concerns about the quality of the care such patients received, Pennsylvania's then-Governor Edward Rendell launched the Prescription for Pennsylvania, a series of reforms to address the quality, affordability, and accessibility of health care.
As the CNF brief explains, two of these reforms leveraged the nursing workforce to improve the delivery of primary care. The first relieved state restrictions on NPs, allowing them to practice to the full extent of their training, a reform that resulted in dozens of NP-staffed convenient care clinics opening around the state.
In addition, Pennsylvania also began to increase its reliance on nurses to provide quality care for patients with chronic conditions. The state's Chronic Care Initiative (CCI) offered financial incentives to primary care practices to implement the widely respected Wagner Chronic Care Model in the context of patient-centered medical homes. The model emphasizes delivery of evidence-based care to an informed and active patient by a team of prepared and proactive practitioners, and it relies on nurses to provide care management.
“The teams are allowing people to take care of patients the way they have always wanted to, or in some cases, allowing them to do what they’ve always done without losing their shirts.”
—Blueprint Associate Director Lisa Dulsky Watkins, MD.
As part of Vermont's ambitious Blueprint for Health program, a broad series of health care reforms, nurse care coordinators in the community now work in clinics and private practices across the state, where they collaborate with social workers, behavioral health counselors and others to transform the delivery of primary care.
Nurses often serve as team leaders, and they and other members of the teams meet with patients to make sure they receive the preventive and coordinated care they need. “The teams are allowing people to take care of patients the way they have always wanted to, or in some cases, allowing them to do what they’ve always done without losing their shirts,” says Blueprint Associate Director Lisa Dusky Watkins, MD.
Another important reform: The state changed its nurse practice act to mitigate physician shortages by allowing experienced APRNs (advanced practice registered nurses) to engage in solo practice.
Early data from the program suggest that the state is on a path to cost containment.
Nationwide, the U.S. Department of Veterans Affairs (VA) maintains a workforce with the equivalent of 8,500 full-time nurses who provide continuous, coordinated primary care to the nation's veterans, playing multiple roles as part of Patient-Aligned Care Teams (PACTs).
Each five-person PACT includes a primary care provider (an NP, physician, or physician assistant), a nurse care manager (an RN), a clinical associate (an LPN or nursing assistant), and a clerical associate. The fifth member of the team is the veteran, who is encouraged to take an active part in making decisions about his or her health.
Each veteran has a PACT RN responsible for coordinating care over the long term, in person or via telehealth technology. This continuity of care over an extended period of time, the VA believes, serves to create strong bonds between nurses, patients, and patients’ families.
Early results from the program show significant reductions in rates of emergency or urgent care visits, and in acute-care hospital admissions, suggesting that the approach is helping improve the health of participating veterans. The VA also anticipates significant cost savings, particularly as more enrollees move into PACTs.
The brief also notes several barriers to the expansion of nurses' primary-care roles. One such barrier is reimbursement systems. According to Clayton M. Christensen, MBA, MPhil, author of the acclaimed 2009 book, The Innovator's Prescription, "[R]eimbursement systems currently trap in high-cost venues much care that could be provided in lower-cost, more convenient business models." He argues that one reason for the high cost of health care is the lack of business-model innovation in the health care industry. Christensen goes on to propose a model that relies on nurses to take primary responsibility in health care practices for the "straightforward diagnosis and treatment of generally acute disorders, such as earaches," and "the ongoing oversight of chronic diseases, such as diabetes."
The brief touches on insurance innovations that are making it affordable for private practices to implement nurse care management programs, and that appear to be lowering overall costs while improving patient health. The next issue of Charting Nursing's Future will explore impediments to the growth of the primary care sector's capacity, including reimbursement mechanisms, and regulatory, policy and financial barriers that make it difficult for nurses to practice to the full extent of their education and training.