Nursing's Rx for Health Care Reform

Use Exemplary Nursing Initiatives to Expand Access, Improve Quality, Reduce Costs, and Promote Prevention

    • April 23, 2009

A Robert Wood Johnson Foundation (RWJF) Charting Nursing’s Future brief identifies nursing initiatives across the nation that collectively point the way to transformation of the country’s health care system. “Nursing’s Prescription for a Reformed Health Care System” combines case studies with analysis and policy recommendations, and arrives on the desks of lawmakers and health care reformers just as Congress and the President begin to piece together what promises to be the most significant overhaul of the nation’s health care system since the creation of Medicare.

“Nurses have created model programs in acute care, primary care and public health settings that are improving the health status of individuals and communities,” the brief declares. “These initiatives are expanding access, improving quality and driving down costs.” The brief goes on to highlight case studies demonstrating exactly that. Among them:

Comprehensive Community-Based Care for the Elderly. The Program of All-Inclusive Care for the Elderly (PACE) uses nurses and other health professionals to provide comprehensive, integrated medical care and social services. Payment is per-patient-served, creating incentives for high-quality care that keeps patients out of acute care settings. PACE was first created in San Francisco by a community organization but is now an optional Medicaid service in 31 states and a permanent benefit under Medicare. States using PACE report that it reduces costs and improves service utilization patterns.

Nurse-Managed Health Centers and Retail Clinics. In the last 30 years, nurses have established more than 250 nurse-managed health centers around the nation, providing care in communities where disparities in health care are most pronounced. At one such clinic, 11th Street Family Health Services, nurses have developed a variety of innovative approaches to managing chronic conditions. But nurse-led practices are ineligible under current rules for the now ongoing Centers for Medicare and Medicaid Services medical home demonstration project, which might otherwise provide much needed financial support to their efforts to provide care to underserved communities.

Transforming the Workplace to Support Quality. A recent study finds that nurses in hospitals spend just one-fifth of their time on patient care—spending the rest tracking down supplies, doing paperwork, and communicating with other team members with often outmoded systems and tools. Meanwhile, faster patient turnover in hospitals due to cost-containment policies means sicker patients and increased work from transitioning patients in and out of facilities. The result: quicker burnout and higher staff turnover. The Magnet Recognition Program of the American Nurses Credentialing Center encourages hospitals to become magnets for nurses by improving their work environment. Similarly, Transforming Care at the Bedside (TCAB), a pilot program of the RWJF and the Institute for Healthcare Improvement whose tools and messages have spread to hundreds of hospitals across the nation, has pioneered nurse-led innovations in medical-surgical units. At one TCAB site, Seton Northwest Hospital in Austin, Texas, nurses now join other members of the interdisciplinary care team on daily rounds, strengthening communication with physicians and improving patient care. Such reforms help retain experienced nurses, improve the quality of care, save money, reduce complications for recovering patients and even save lives.

The brief highlights other reform approaches, including:

  • Reforming state and federal laws. Law and regulations in 23 states permit nurse practitioners to practice independently, but in 27, they must either practice under the supervision of, or in collaboration with, a physician. Reforms that allow and encourage nurses to practice to the full extent of their training could significantly expand access to care.
  • Investing in school nursing. School nurses do much more than tend to minor injuries these days. They identify health problems that affect learning, administer medications for physical and behavioral conditions, provide health counseling and education on smoking and obesity, conduct surveillance for communicable diseases, join in emergency preparedness activities and enable students with disabilities to be educated with their peers. Just as important, they are often the gateway to other medical services. But fewer than half of public schools in the United States have a full-time registered nurse on staff.
  • Engaging nurses in development of health information technology (HIT). Nurses have a unique and vital vantage point on the potential of health information technologies in the health care workplace. The brief quotes Lillee Gelinas, R.N., M.S.N., F.A.A.N., vice president and chief nursing officer, VHA Inc., an alliance of more than 22,000 health care organizations: “Because nurses are integral to health care, they must be integral to improvements in that process. Their knowledge of patient care, interdisciplinary communication and care transitions equips them to act as ambassadors between patients and the health system. Excluding them from the development and design of HITs will sabotage successful implementation.”

“Health care reform in the United States can only succeed if we put all of our resources to their best use,” says Susan Hassmiller, Ph.D., R.N., F.A.A.N., RWJF’s senior adviser for nursing. “In the case of nursing, that will require a number of structural reforms. We expect this brief to help point the way.”

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About the Series

For more than a decade, Charting Nursing’s Future has assembled research and expert opinion to inform readers about policies and best practices that are transforming nursing, health care and public health. Propensity LLC currently produces this series.