Nurse Leader Explains What Nursing's Got to Do with Health Care Reform

    • June 10, 2009

Foundations should help convince policy-makers to incorporate nurse-led innovations into health reform, according to Diana Mason, R.N., Ph.D., editor-in-chief of the American Journal of Nursing.

“Any chance you have when you’re speaking to policy-makers or at a public forum, you should say, ‘nurses have solutions, and we need to listen up,’” said Mason, the featured presenter at the National Nurse Funders Collaborative’s (NNFC’s) first webinar entitled “Health Care Reform: What’s Nursing Got to Do with It.” “The contributions that nurses can make to our nation are incredible.”

The NNFC is a network of funders that work together to improve the health and well-being of communities through philanthropic support for nursing education and practice. The Robert Wood Johnson Foundation and the Northwest Health Foundation sponsored the May 11 webinar.

Mason encouraged foundations to raise the visibility of nurse-led models of patient care by convening roundtables of policy-makers, journalists and community leaders to discuss ways to incorporate the evidence-based models in their communities.

“[Nurses] have an infrastructure of models of care focused on primary care, chronic care management, care coordination and wellness, which is just what our country is saying it needs,” she said.

Dissemination of these models of care, however, has been slowed by inadequate reimbursement and opposition from physician groups who maintain that to ensure quality, only physicians should lead multidisciplinary care teams.

Mason noted the need to improve reimbursement and to “work with our colleagues in medicine [so that they] understand that their work is not threatened—there’s enough work to go around here.” 

She noted that most nurse practitioners prefer to work in a collaborative arrangement with their physician colleagues. However, some areas lack primary care physicians.

For example, two nurse-led models of care—Convenient Care Clinics and Nurse-Managed Centers—are prevalent primarily in underserved urban and rural areas with a shortage of primary care physicians.

Convenient Care Clinics, which serve 3.5 million people in supermarkets, retail stores and pharmacies throughout the United States and are often staffed by physician assistants and nurse practitioners, stay open after many primary care clinics close.

Mason said physician groups have raised concerns about the quality of the Clinics, recommending that primary care physicians have jurisdiction over them. However, all Clinics follow protocols, and patient satisfaction rates exceed 90 percent.

Mason pointed to recent research published in Health Affairs showing that the Clinics serve a safety-net population who often don’t see a primary care physician. In addition, people who use them generally get treated for relatively minor problems like sinusitis or immunizations. She believes they could help reduce the demand for emergency room services.

Mason said research has demonstrated that the quality at the Clinics is as good as that provided by primary care physicians and urgent care centers. She added that nurse practitioners and physician assistants refer patients to primary care physicians if needed.

Nurse-Managed Centers are located at Schools of Nursing and provide primary care to underserved populations. They offer primary care and a variety of community-based services such as nutrition classes, family planning, mental health care and drug abuse treatment.

Mason pointed to evidence showing that these Centers have reduced emergency room use, hospital days and the incidence of low birth-weight babies. However, Nurse-Managed Centers struggle to survive amidst low reimbursement rates for nurse practitioners and other barriers, including a national proposal to require “medical homes” to be physician led.

Mason contends that more flexibility is needed in defining who can head a medical home, particularly for Centers in rural areas without affiliated physicians and states where nurse practitioners can practice independently.

If nurse practitioner-led Centers qualified as a “medical home,” Mason believes the Centers could help the Obama administration reach its aim of increasing the number of community health centers.

She also discussed the Transitional Model of Care, designed by Mary Naylor, R.N., Ph.D., R.N., RWJF’s Interdisciplinary Nursing Quality Research Initiative director and a professor at the University of Pennsylvania School of Nursing. Under the model, an advanced practice nurse serves as the primary care coordinator to help elderly patients avoid hospitalizations and promote longer-term positive health outcomes.

The nurse meets with a hospitalized patient to coordinate service, evaluate medications and establish a post-discharge plan of care that meets with patient’s and the caregiver’s goals. Within a day of being released from the hospital, the nurse visits the patient’s home.

This Transitional Model of Care has demonstrated improved quality and cost outcomes for at-risk older adults compared with standard of care treatment, according to three randomized, controlled studies sponsored by the National Institute of Nursing Research. At 26 weeks, 28 percent of patients in the Transitional Model of Care group returned to the hospital compared with 56 percent of patients receiving standard care. The program resulted in more than $5,000 saved per Medicare patient.

Mason also advocated for certified birth centers for women at low pregnancy risk to be “the frontline of all maternity care in the United States.”

She presented data from the Family Health and Childbirthing Center in Washington D.C., founded and run by Ruth Watson Lubic, Ph.D., C.N.M.

The Center had nearly half the cesarean rate in 2005 as the rest of the city (15 percent versus 28 percent) and significantly lower rates of premature and low-birth rate babies, resulting in $1.2 million in cost savings. If spread nationwide, the model could save almost $13 billion just for Medicaid-funded deliveries.

However, many certified birthing centers struggle to remain financially viable, particularly after the Centers for Medicare & Medicaid Services concluded in 2007 that it had no mandate to pay the facility fee. The agency subsequently ceased payment, even though it had paid the fee since 1987 and continues to pay the fee to hospitals.

The last model of care that Mason discussed will be funded and disseminated: President Obama has pledged $8.6 billion over 20 years for the Nurse-Family Partnership, and the 2010 budget contains $124 million for the program.

The Nurse-Family Partnership pairs a nurse with a low-income, first-time mother. Over two decades, the program has showed significantly better pregnancy outcomes, reductions in high-risk and subsequent pregnancies, fewer injuries among children, reduced child abuse and fewer language delays among children.

The program has generated a $5.70 return for every dollar invested and a net benefit to society of $17,000-$34,000 per family served, according to Mason.

If you work at a foundation and are interested in signing up for future National Nurse Funders Collaborative Webinars, e-mail Cathy Malone at: