The New Health Dialogue

Let's zoom in on one aspect of the new report on "The Future of Nursing: Leading Change, Advancing Health" -- nurses' role in primary care aimed at managing chronic disease, particularly in high risk, underserved populations.

The report, the result of a two year initiative from the Robert Wood Johnson Foundation and the Institute of Medicine, will fuel the ongoing fight, federally and in the states, over "scope of practice" - ie letting nurses with post-graduate degrees do more complex care, with less supervision from physicians. People who see Advanced Practice Nurses as part of the solution to the primary care workforce like this; doctors generally don't. (My colleague Meredith Hughes has posted on this topic here, here, and here and Mary Agnes Carey and Andrew Villegas at Kaiser Health News did a really good job of illustrating the crosscurrents.)

The report came down on the side of doing a better job of using the 3 million-strong nursing workforce. KHN quoted Donna Shalala, the former Health and Human Services Secretary who chaired the committee, as saying:

We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system -- in leadership, in education and training, and in the design of the new health care system... We can’t be fighting with each other if we really are going to have a high quality system that we can afford.

For starters, the report featured four major recommendations about the future of the nursing profession (about 3 million strong in the US):

• Nurses should practice to the full extent of their education and training [ie the scope of practice/how much medical oversight debate];
• nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;
• nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and
• effective workforce planning and policy-making require better data collection and information infrastructure.

The chapter I turned to in most detail is called "Transformation Models of Nursing Across Different Care Settings." It begins:

We are now challenged as the health care needs of the population change from an acute and infectious disease focus to that of an aging population with chronic disease. The cost of health care is rising and the number of people who are poorly served by our health care system is increasing. Along with the change in the health care landscape we are facing a nursing workforce shortage and a nursing leadership shortage.

It explores:

• Transformational Partnerships in Nursing Education
• Innovative Nursing Education Curriculum
• Acute Care
• Chronic Care
• Palliative and End-of-Life Care
• Community Health
• School Health

Let's take a brief look at the Chronic Care section, which highlights five-nurse led innovations:

Transformacion Para Salud

Funded by HRSA, this demonstration at project at the Larry Combest Community Health and Wellness Center, a nurse-managed primary care center, involving having Advanced Practice Nurses oversee community health workers who provide intensive care coordination involving home visits and telephone calls to patients enrolled in a chronic disease management program. The "interdisciplinary team takes into account social determinants of health in care delivery, and involves engagement of a community advisory board in the program implementation." There are early indications that it is having a positive impact on health. Fiscal sustainability beyond the grant period is a problem as the current health care system doesn't reimburse these services.

Intensive Primary Care

The St. Vincent’s Nurse-Managed Health Center, operated by the University of Texas Medical Branch School of Nursing, offers comprehensive primary care to uninsured residents of the Galveston area. The center uses "Intensive Primary Care" (nurse practitioners, nurse managers, and other services) for adults with chronic health problems, and who quite simply need more medical care, just like some hospital patients need more intensive care than others. 

The Nursing Mobile Healthcare Project

The University of Medicine and Dentistry of New Jersey School of Nursing with the Children’s Health Fund, is running the d Mobile Healthcare Project for medically underserved populations in four New Jersey cities. "Since March 2006, patients have been treated for both acute and chronic illnesses within the scope of practice of Advanced Practice Nurses. The Project serves as a practice site for nursing and medical faculty, and as a clinical rotation for nursing and medical students.

Immigrant Health Service, Inc. Nurse Managed Health Centers                                                                                                     

This is a HRSA funded voucher program, designed to help Hispanic migrant and seasonal agricultural workers. In Minnesota and North Dakota, It involves year round clinics, seasonal satellite nurse-managed centers and two mobile units, and patient outcomes have improves. In addition "Cluster Clinics", or mini-clinics,are arranged in a sort of one-stop shopping so patients can spend two or three hours there and receive  medical care, diabetes education, and counseling.

Centura Health At Home

Centura Health At Home, the largest home care organization in Colorado, has a "telehealth" system for congestive heart failure patients. Nurses monitor patients daily and do "video visits." "Vital signs, oxygen saturation rates, and auscultation of heart and lung sounds using NASA technology stethoscopes is collected though the patient may be up to 50 miles away." When necessary, a nurse can arrange a home visit, possibly heading off another crisis and hospitalization. The 30-day hospital re-admission rate is for this group is 9.7 percent -- versus more than 20 percent nationwide for primary diagnosis of CHF."

A number of these programs (depending on state law) faced barriers because of oversight requirements that hamper how much primary care APNs can provide, and because -- outside grants -- the current health care system does not reimburse for some of these care coordination and monitoring services. Whether or how much this report's recommendations get implemented will depend in part on state legislatures -- and in part on how creatively and effectively we seize on some of the opportunities for team-directed care and better care management that we will have in some the demonstrations, pilots and realigned incentives in health reform.