Evolving Nursing Practice and Patient Care Delivery Models

Introduction: Healthcare Challenges Driving Nursing Change

The future of nursing involves several healthcare delivery challenges that, while somewhat unique to the United States, also appear in other nations. Population aging is one issue generating increased demand for healthcare services. A growing number of individuals across all age groups suffer from chronic illnesses; approximately 50% of U.S. citizens have been diagnosed with conditions such as arthritis, diabetes, cardiovascular disease, mental disorders, and hypertension (Reinhard & Hassmiller, n.d.).

A 2009 AARP report on chronic conditions noted that patients and caregivers have firsthand experience of the absence of care coordination among healthcare workers, typically leading to unnecessary repeat hospitalizations, redundant procedures and examinations, and difficult hospital-to-home transitions. An acute shortage of professionals—including nurses—is already being experienced, particularly in low-income neighborhoods and rural regions. These deficiencies are likely to worsen as the existing workforce retires and healthcare demands continue to mount (Reinhard & Hassmiller, n.d.).

Nurse-Managed Health Clinics

A transformation of the healthcare workforce is necessary to address these challenges. The solution is not as simple as increasing the number of clinicians. The health sector requires professionals who are well prepared to care for patients with multiple chronic conditions across every care setting. Moreover, providers should be capable of delivering care to the fullest extent consistent with their training and educational qualifications. Since nurses constitute the largest segment of healthcare professionals and possess both adaptive capacity and scientific knowledge, they are well positioned to lead necessary healthcare transformations. To do so, nurses must take on re-conceptualized and enhanced roles in transitional care, health coaching, quality improvement, chronic illness management, and disease prevention (Reinhard & Hassmiller, n.d.).

The landmark Institute of Medicine (IOM) report published in 2010 on the future of nursing stated that, with the anticipated millions of additional patients expected to access healthcare services under the Affordable Care Act (ACA), Advanced Practice Registered Nurses (APRNs) must play a significant role in care delivery. The report, which resulted from a Robert Wood Johnson Foundation (RWJF)-sponsored initiative, revealed that research data on APRNs—as well as the experiences of Kaiser Permanente, Geisinger Health System, the Veterans Health Administration, and other healthcare institutions that have expanded nurses' patient-care responsibilities—demonstrate that APRNs deliver high-quality, safe primary care. The report's authors also warned lawmakers of numerous restrictions, including those embedded in Medicaid and Medicare reimbursement policies and state-level practice acts, that prevent effective nurse response to a rapidly evolving healthcare system. These obstacles must first be overcome to ensure that nurses are effectively positioned to lead change and advance health outcomes. One of the IOM's key recommendations was the elimination of barriers to nursing practice scope, enabling nursing practice to occur at the fullest extent of nurses' training and education (ANA, 2011).

Continuum of Care and Accountable Care Organizations

Positive outcomes in terms of healthcare value, quality, and access can be achieved through the expansion and re-conceptualization of nurses' roles and the maximization of nursing practice scope relative to education and training. Marilyn Chow, vice president of Kaiser Permanente's Patient Services Program Office, noted in the IOM report that while their organization reflects the future of healthcare, such models are not yet widespread. The Veterans Affairs Department (VA), Kaiser Permanente, and Geisinger Health System serve as examples of healthcare institutions that have successfully maximized nursing practice scope. These institutions implemented initiatives that produced practical evidence of the positive impact that nurses—practicing at their fullest scope-of-practice levels—have on patients and on the overall care delivery system (Ridge, 2011).

The VA's shift from a clinic-based system to a primary-care-focused organization was built on the expanded use of nurse practitioners (NPs) as primary care providers. At the VA, NPs practice across a continuum of care within an organizational culture that supports professional teamwork. By 2007, patients of the organization were receiving considerably more economical and higher-quality care compared to similar populations enrolled in Medicare. Geisinger, a private not-for-profit organization, transformed from a specialty-centered, high-cost medical center into a high-value system. Its vision includes enabling employees to work at the maximum level of their licensure and redistributing care-delivery responsibilities to reduce costs and improve quality. Under this model, call center nurses transitioned into primary care facilities, developed relationships with patients and their families, created better care plans, and thereby reduced hospitalizations. Geisinger also established its own convenient care centers staffed by NPs (Ridge, 2011).

Conclusion: Nursing's Role in Health System Transformation

The feedback obtained from department NPs largely agrees with current health reform research: reforms in healthcare are progressively aimed at boosting and extending primary health structures, with a shift in care from clinics to communities. There is a renewed focus on disease prevention and health promotion, which seeks to stem the tide of chronic illness and sustain adequate chronic disease management, while also addressing health inequalities and expanding access to affordable services. In view of the full scope of nursing practice, the success of health infrastructure reforms—such as those underway in Australia and the United States—depends on an adequately qualified nursing workforce that is supported in advanced practice nursing roles across a variety of settings (Wilson, Whitaker, & Whitford, 2012).

Bibliography

ANA. (2011). Advanced practice nursing: A new age in health care. American Nurses Association, 1–7. Retrieved from

Reinhard, S., & Hassmiller, S. (n.d.). The future of nursing: Transforming health care. AARP International: The Journal. Retrieved from

Ridge, R. (2011). Future of nursing special: Practicing to potential. Nursing Management, 32–37. Retrieved from http://www.nursingcenter.com/journalarticle?Article_ID=1176058

Wilson, A., Whitaker, N., & Whitford, D. (2012). Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives. The Online Journal of Issues in Nursing. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Rising-to-the-Challenge-of-Reform.html