¶ … Evolution of Nursing Roles in an Enlarged National Health Care System The Affordable Care Act enables the provision of health insurance to 30 million people above the coverage figures prior to the enactment of the law. Because of this precipitous rise in the number of health insurance members, access to care as a function of the availability of primary care providers has been a leading issue in the transition to the nation-wide system of health care insurance. Public health models and nursing practice arrangements are changing in order to meet the immediate and anticipated care needs that have been brought to bear on the health care systems.

Public Health and Nurse Managed Health Centers (NMHCs)

From the earliest days of public health, the roles of nurses have been embedded in the social, educational, and political needs of communities. Health education has functioned as a springboard to community organizing, patient advocacy, and the development of integrated health care systems (Kulbok, et al., 2012). This same broad perspective is seen in the contemporary implementation of public health, the success of which depends on the skillful collaboration of public health nurses across agencies and in the community (Kulbok, et al., 2012). This orientation to community is evident in the community participation and ethnographic health promotion model" that serves as a foundation for addressing multi-causal, complex health-related problems in the community (Kulbok, et al., 2012). Nurse managed health centers or clinics are an exemplar of the community participation health promotion model.

Nurse managed health clinics operate as non-profits and typically provide care to underserved populations and offer an option for sliding scale fees (Kulbok, et al., 2012). Advanced practice nurses lead the provision of primary healthcare services at nurse managed health clinics, and focus the agency on disease prevention, health education, and health promotion.

Concepts of Continuity or Continuum of Care

The concept of continuity of care is grounded in the perspective of the patient. Specifically, the continuum of care is concerned with whether health care is perceived by the patient as coherent and linked across all facets of patient care, including the flow of good information, quality interpersonal skills, and effective care coordination. The concept of continuity of care has relevance to the evolution of healthcare that is top-of-mind and integral to current healthcare practice as it incorporates discrete elements of care that have traditionally been under the aegis of one organization or another, however, the state of flux may reposition elements of care such that ensuring the maintenance of coherency and the support of a linked continuum of care becomes a substantive challenge.

The distinct challenges of each type become salient when considering the definitions of the elements of care. Informational continuity can be said to be taking place when patients' current care is informed by prior health events and the past provision of healthcare services. Relational continuity ensures that the patient is viewed as and known as an individual and unique person, such that an enduring relationship between providers and patients exists and serves to connect patient care over time and to bridge events that are discontinuous because of the passage of time or different locations and/or providers. Management continuity is crucial to the provision of effective medical and health care for chronic conditions, and is characterized by strong links across different providers who serve the same individual patient.

Accountable Care Organizations (ACO)

The establishment of an Accountable Care Organization (ACO) is a voluntary effort to address the erosion of care quality for Medicare patients that has been an artifact of a poorly functioning reimbursement system ("CMS," 2005). The hospitals, physician groups, and other types of healthcare providers volunteer to provide high quality, coordinated care to Medicare patients ("CMS," 2005). The clear-sighted objectives of Accountable Care Organizations is to provide the right type and level of care to patients at the right time, and to ensure that services are not unnecessarily duplicated, and that medical errors are systematically prevented ("CMS," 2005). In addition to these laudable goals, Accountable Care Organizations are motivated to revamp services, spend health care dollars more effectively, and to deliver high quality patient care since doing so will enable the ACO to share a portion of the savings in Medicare program expenditures (see http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/Downloads/ACO-Menu-Of-Options.pdf) ("CMS," 2005).

Medical Homes

Across the country, states are addressing the costs of Medicaid spending by establishing patient-centered medical home (PCMH) models of care. Comprehensive preventive and primary care is offered in these...

Three key prongs of reform support the patient-centered medical home model: 1) Expanded access through extended office hours and enhanced communication between providers and patients through phone and email; 2) increased coordination of care and enhanced overall quality of care; and 3) reductions in healthcare costs. Taking a wrap-around approach, a provider team consisting of "physicians, nurses, nutritionists, pharmacists, and social workers" works together to meet the healthcare needs of patients. The medical home model emphasizes a holistic approach in which all aspects of healthcare are integrated in order to capitalize on the potential to increase access to community-based social services and to improve behavioral health, physical health, and the management of chronic health conditions.
Feedback from Nurse Colleagues

The nurse colleagues who agreed to provide feedback on my presentation most often commented on three major areas of concern: 1) Certification barriers that get in the way of changing nursing roles, 2) issues related to continuity of care which appears to be in jeopardy and vulnerable to erosion under the wide scale changes that are occurring as a result of healthcare reform, and 3) the difficulty of establishing and maintaining multidisciplinary teams that require extensive and meaningful collaboration in order to achieve their stated goals.

More than one colleague expressed concerns about the major barrier to changing the roles of nurses in managed care organizations that is the result of the unwillingness to credential nurse practitioners as primary care providers. As colleagues pointed out, this hurdle impedes the ability of centers to get reimbursement from private insurers. One colleague cited a recent study in which only 53% of managed care respondents offered credentialing to nurse practitioners and of these respondents, only 56% were reimbursing primary care nurse practitioners at the same rate as primary care physicians.

An important foundation for addressing continuity of care is ensuring that definitions are clearly established and agreed upon by practitioners and patients. Nurse colleagues expressed concern that the definitions for continuity of care were not clear, were not generally agreed upon, and that this lack was impacting conversations about coherent care and also limiting meaningful evaluation of care coherency. There was general agreement that establishing definitions is essential to the accurate measurement and evaluation of continuity of care. Three fundamental types of continuity of care have been identified in the literature I reviewed: 1) continuity of information, 2) continuity of personal relationships, and 3) continuity of clinical management. Each of these types of elements of continuity of care must receive sufficient consideration as the field of nursing and the provision of healthcare in newly integrated community settings progresses. From this perspective, the nurse colleagues who weighed in on continuity of care in reformed healthcare contexts were in alignment with research findings I reviewed.

The perspectives that nurse colleagues shared indicated that multiple measures are necessary if all the facets of healthcare that impact continuity of care are to be measured and evaluated. Contemporary measures of healthcare are undergoing transitions, which locates healthcare providers in a holding pattern as assumptions about indicators that are presumed to measure continuity of care are tested for reliability and validity, and the capacity to accurately reflect the status of informational, relational, and/or management continuity. Moreover, there must be assurances related to the direct measures of continuity such that the patients' perspectives are truly measured and transformations that occur as care is provided across agency borders are captured.

The multidisciplinary team approach to healthcare has been in existence for several decades, and the wraparound model has clearly demonstrated advantages for patients. However, nurse colleagues were dubious that it would easy to put these models in place and maintain them over the long haul, absent robust incentives to do so. A second nurse colleague insisted that national accreditation would be the key to reform, and that seeking formal recognition as patient-centered medical homes would bring fiscal incentives in the form of enhanced reimbursement rates or the innovative coordination of care that does not necessarily exist in the current configurations.

A third nurse colleague held out the importance of health information technology (HIT) since the multidisciplinary teams of the medical home model and the accountable care organizations can be either physical teams or virtual networks of providers who offer services and care. Communication across these team members is facilitated by the health information technology available to healthcare organizations with the budgets and the inclinations to avail themselves of the technology and establish the necessary infrastructure.