6
Testimony

Prior to the forum in Philadelphia, a variety of stakeholders and the public were invited to submit written testimony to the committee in four areas relevant to nursing care in the community: public health, community care, primary care, and long-term care. Those submitting written testimony were asked to describe innovative models in these four areas; barriers that nurses face in delivering care in the community; and how nurses could be further involved in advancing these areas of nursing across community settings.

Fifteen individuals at the forum provided prepared, oral testimony for the Initiative on the Future of Nursing; in most cases, these individuals or the organizations they represented also presented written testimony. Many important ideas and suggestions for the initiative emerged from this testimony and are summarized below. A number of other individuals attending the forum offered ad hoc observations and opinions on what was discussed. These comments are summarized at the end of this chapter. Like the presentations of the speakers, the testimony, observations, and opinions in this chapter should not be interpreted as positions or recommendations of the committee, the Robert Wood Johnson Foundation, or the Institute of Medicine.


Dana Egreczky, Vice President of Workforce Development

New Jersey Chamber of Commerce


For the past decade, the cost of health care has been among the top three concerns of business leaders, along with increasing taxes and fees and the lack of a qualified workforce, said Dana Egreczky, vice president



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6 Testimony Prior to the forum in Philadelphia, a variety of stakeholders and the public were invited to submit written testimony to the committee in four areas relevant to nursing care in the community: public health, commu- nity care, primary care, and long-term care. Those submitting written testimony were asked to describe innovative models in these four areas; barriers that nurses face in delivering care in the community; and how nurses could be further involved in advancing these areas of nursing across community settings. Fifteen individuals at the forum provided prepared, oral testimony for the Initiative on the Future of Nursing; in most cases, these individu- als or the organizations they represented also presented written testi- mony. Many important ideas and suggestions for the initiative emerged from this testimony and are summarized below. A number of other indi- viduals attending the forum offered ad hoc observations and opinions on what was discussed. These comments are summarized at the end of this chapter. Like the presentations of the speakers, the testimony, observa- tions, and opinions in this chapter should not be interpreted as positions or recommendations of the committee, the Robert Wood Johnson Foun- dation, or the Institute of Medicine. Dana Egreczky, Vice President of Workforce Development New Jersey Chamber of Commerce For the past decade, the cost of health care has been among the top three concerns of business leaders, along with increasing taxes and fees and the lack of a qualified workforce, said Dana Egreczky, vice president 41

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42 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY of workforce development for the New Jersey Chamber of Commerce. Her state in particular has some of the highest health care costs in the country, which is why the New Jersey Chamber of Commerce made health care one of six planks in its Platform for Progress, a strategic ini- tiative designed to give the state a more vibrant environment in which business can thrive. A partnership between the Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce Foundation led to the New Jersey Nursing Initiative (NJNI), which is working to ensure that New Jersey has the well-prepared, diverse nursing workforce it needs to meet the demand for nursing in the twenty-first century. The grant has supported several new and innovative projects through the NJNI, such as an online service to help prospective students interested in nursing apply to multiple institutions around the state using a single application, an online service to optimize the number of clinical placements for nursing students, and development of a remediation language center for students. Egreczky said the nursing community needs to reach out to the business community to ensure that nurses are available to improve the quality of life for patients and communities. Engaging the employer community has several benefits; Egreczky described three of these benefits. First, business leaders can help elevate the discussion of the future of nursing from a health care argument to an economic develop- ment argument; for example, they can point out to policy makers that they will have to fire or not hire new people as health care costs increase. “And if we have learned anything in the last few months, under the cur- rent economic crisis, it is that nothing puts as much fear into a politi- cian’s heart as the loss of jobs among the electorate. So use that to your advantage,” said Egreczky. Second, the business community can advocate for nurses’ vision of the future. Nurses can use the high costs of health care—in terms of di- rect costs, lost productivity, and days away from work—to engage the interests of business leaders. Business leaders need to know that the looming crisis being generated by these costs is both “foreseeable and avoidable.” However, they will not get involved unless the nursing community is unified. Egreczky also cautioned against asking the busi- ness community to support actions that would raise taxes or fees and she suggested approaching small, young companies as well as large, estab- lished companies in building support for nursing. Egreczky said, “When you seek a spokesperson, consider recruiting the president of a small company that is truly representative of the world of business and there-

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43 TESTIMONY fore truly feeling the pain of increasing percentages of revenue that em- ployee health care costs are absorbing.” Finally, “never underestimate the power of a third-party broker that can exert pressure on the system,” Egreczky said. The business commu- nity can make the case that rising health care costs will cause fewer peo- ple to have jobs, which will degrade the regional tax basis. “That is enough to make elected officials, college professors, and regulatory mavens—the very people we need to influence—sit up and take notice.” Skip Voluntad, Volunteer AARP Nurses are a vital link between patients and safe, high-quality health care, said Pioquinto (Skip) Voluntad, a volunteer with AARP. Though their role is often taken for granted, nurses are “touch points in nearly every interaction between the patient and the provision of care.” AARP works with policy leaders, states, and the nursing community to increase awareness of the role that nurses play and the dire situation that the health care system must face unless the supply of highly skilled nurses is increased. Voluntad described himself as a 79-year-old diabetic male with kid- ney failure. “I work with the primary care doctor and a kidney specialist, and I would not be here today to offer this testimony were it not for their knowledge and abilities. But I needed more. It was my great fortune that the nurses who work with my doctors also offer a great wealth of knowl- edge, and they are readily available when I have questions or need refills on my prescriptions. Many of them made it a point to know me person- ally, by phone when I could not see them in person. They all know me as Skip.” Voluntad noted that visiting nurses have checked on his diabetic treatments, monitored his blood pressure, and helped with his medicine doses at home, saving both him and his doctor considerable time. They have helped him with his living will. In addition, Voluntad’s son had several operations, and during the year before his death, nurses were a great comfort to him, to Voluntad, and to the rest of the family. Because of his exposure to the health care system, Voluntad learned from nurses that they were puzzled as to why so few Asian Americans in the surrounding community took advantage of the health care offered by the Delaware County Memorial Hospital. He teamed up with other

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44 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY Asian-American activists in the community and with nurses to better un- derstand and remove barriers to care. One of the greatest barriers was a language barrier. “The solutions to this problem required no new tech- nology, no complex information systems, no new funding formulas—just care, common sense, and commitment,” said Voluntad. Nurses and other health care professionals created a neighborhood response team and ar- ranged for translators. In addition, hospital departments offered classes to members of the Asian-American community. A program available to all community members in eight different languages greatly increased the comfort levels of Asian Americans visiting the hospital, contributing to a 20 percent increase in the number of patients from the Asian-American community. “Why were they successful?” Voluntad asked. “Because trying to understand patients’ needs—medical and otherwise—is what nurses do.” At the same time, nurses learned about family relationships, dietary dif- ferences, and philosophical distinctions between Eastern and Western medicine. “Is this kind of effort enough to solve the enormous health care challenges that we face? Certainly not. But just as certainly without including nurses as a key part of the solution we cannot succeed, which is why AARP supports an increased focus on advanced nursing educa- tion to ensure that we all have highly skilled nurses when and where we need them,” concluded Voluntad. Samuel Albrecht, Executive Director Commission for Case Manager Certification Case management and care coordination are well-established prac- tices primarily performed by registered nurses, said Samuel Albrecht, executive director of the Commission for Case Manager Certification (CCMC). Certified case managers work collaboratively across the entire spectrum of the health and human services continuum to assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet their clients’ needs. Certification, which requires spe- cialized skills and knowledge, is based on field research and a test. Nurse case managers work in a variety of settings, but they perform care coordination and case management in community health to a greater extent than in any other arena, said Albrecht. In community health set- tings, nurse case managers use appropriate medical, psychosocial, and community resources to meet patient’s holistic needs for high-quality

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45 TESTIMONY and timely access to necessary services. Nurse case managers also lead and participate in multidisciplinary teams to achieve desired outcomes using evidence-based guidelines. Many models being considered as part of health care reform contain a care coordination component. As new models of health care are piloted and improved, care coordination and case management will remain es- sential elements, said Albrecht. In the future, nurse case managers will increase their use of technology—including electronic medical records, data mining, and biometric data—to obtain information and communi- cate with patients, providers, and other stakeholders. Through continued certification, nurse case managers will continue to seek optimal out- comes for their clients and ultimately for the public. Gloria McNeal, Professor of Nursing and Associate Dean for Community and Clinical Affairs, University of Medicine and Dentistry of New Jersey School of Nursing Gloria McNeal, serves as a project director for a nurse-managed mobile health care clinic, in addition to her roles at the University of Medicine and Dentistry of New Jersey School of Nursing. The clinic provides primary care services at 20 different locations in four cities in New Jersey. Its goal is to provide primary care services through advanced practice nurses in an interdisciplinary setting to patients who are uninsured. The services provided by the mobile clinic include diag- nosis, management, and treatment for a variety of ambulatory care sensi- tive conditions. Due to grants totaling $3.5 million, the services provided by the mobile clinic are completely free to the clients it serves. Several weeks ago, a client with four children came aboard the clinic’s vehicle and said that even though she was covered by Medicaid, her physician had told her that he does not see more than 10 percent of his patients through Medicaid and that therefore he would not accept Medicaid coverage for her or her children. “That caused a light bulb to go off in my head,” said McNeal. “Just because you are insured does not guarantee access.” As a result, the clinic has begun providing services to both uninsured and underinsured patients. McNeal has approached third- party payers to explain the role of the mobile nurse-managed clinic and to ask if they would reimburse the clinic’s care. However, the payers re- sponded that because the clinic is mobile and not a fixed site, it techni- cally does not exist and cannot be covered, despite the fact that the

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46 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY services are available around the clock and each call it receives is an- swered either in person or through an answering service. “My plea is to identify solutions and recommendations that will allow third-party payers to recognize mobile nurse-managed clinics, because it has been docu- mented that they get into the communities and provide needed care,” said McNeal. Elaine Tagliareni, Professor and Independence Foundation Chair Community College of Philadelphia Over the past decade the Community College of Philadelphia has partnered with Drexel University and Thomas Jefferson University to participate in a Bridges to the Baccalaureate Program funded by the Na- tional Institutes of Health (NIH) to support minority students who are completing an associate degree. In addition, the program has obtained funding from a foundation to support 36 graduates of the program through their bachelor’s degree, with most of the students engaging in community health activities in nurse-managed health clinics. The results of the program have been “stunning,” according to Elaine Tagliareni, professor and Independence Foundation chair at the Commu- nity College of Philadelphia. Ninety percent of the students have com- pleted their bachelor’s degree, and as of 2008, 60 percent had completed their master’s degree, with an additional 17 percent currently enrolled in graduate programs. National statistics vary, but typically show that just over 20 percent of associate degree recipients and nurses prepared ini- tially in baccalaureate programs continue their education, moving on to higher degree levels (HRSA, 2004a). Even more spectacular, said Tagliareni, is that 100 percent of the graduates have returned to work with vulnerable populations in community-based settings. “Their work as advanced practice nurses has made a vital contribution to addressing health disparities and managing chronic care in the local community,” noted Tagliareni. This is a relatively small example, Tagliareni said, “but it packs a powerful message.” Through faculty support, funding at the point of en- try into nursing, and subsequent collaborative relationships throughout all levels of nursing, students from minority backgrounds can gain a new vision of what they can do and return to local communities as advanced practice nurses ready to give culturally sensitive care to vulnerable popu- lations. Bringing programs such as this to scale in a reformed health care

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47 TESTIMONY system will be vital to reducing health disparities and increasing the numbers of minority nurses, concluded Tagliareni. Martha Dewey Bergren, Director of Research National Association of School Nurses School nurses represent a tremendous economic investment in the nation’s children, said Martha Dewey Bergren, director of research at the National Association of School Nurses. The nation’s 66,000 registered nurses who work in school settings straddle the boundaries between community, education, and home. They do not go into the community; they are already embedded in the community. They promote health, pre- vent injury and illness, provide 40 percent of child mental health services in the United States, and connect families and children to health insur- ance and a medical home. School nurses provide the only access to health care for many children who are homeless, immigrants, refugees, and underserved in both rural and urban areas. They are onsite champi- ons for healthy eating, physical activity, indoor air quality, and green cleaning. They provide case management for children with asthma, dia- betes, and anaphylactic food allergies. They also are integral to public health through their work in immunizations, disease surveillance, and dental, vision, and hearing screening. However, one-quarter of the nation’s children do not have a school nurse, Bergren said. On average, each school nurse serves 1,151 students and 2.2 schools. There is not a shortage of school nurses per se, but there is a shortage of positions for school nurses. In fact, surveys show that school nurses are the most satisfied of all nursing subspecialties, said Bergen. To maximize the investment in school nurses, they need to have ac- cess to electronic health records. Already, more than half of school nurses are using such records, which helps them link students with pri- mary care providers and community services. School nurses also have been engaged in some promising pilot projects in telehealth. Today, school health is funded by the education system, which represents a cost shift from the health care system to the education sys- tem. Instead, school health services should be funded from outside the education system, Bergren said.

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48 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY Sharon Moffatt, Chief of Health Promotion and Disease Prevention Association of State and Territorial Health Officials Public health nursing is a critical component of public health and the nation’s health system, said Sharon Moffatt, chief of health promotion and disease prevention for the Association of State and Territorial Health Officials. Public health nurses have historically comprised 20 percent of the public health workforce at the state and local levels. They provide maternal-child health, respond to disasters ranging from floods to terror- ism to hurricanes, offer a unique population-based knowledge, serve as a link between direct care and population-based practice, contribute to health policy, and have a long history of adapting to the changing health needs of communities. In Vermont, for example, Moffat said that public health nurses are members of community health teams that work with primary care offices to connect high-risk patients to community resources. The public health nurse brings to the team expert knowledge of population-based analysis, state and local resources, and evidence-based interventions. They can identify gaps in services and barriers to access and can foster change at the community and state levels. Community health teams in Vermont are funded by private insurers, Medicaid, and state general funds, and in the very near future teams also will be funded by Medicare. Public health nurses have an opportunity to make a significant con- tribution to a more accessible, affordable, and accountable health care system. Yet states are experiencing serious declines in public health nursing positions, Moffatt said. A prominent role for public health nurses in community health teams would be an excellent way to link clinical health care with public health and should be considered by the committee as it develops its recommendations. Teresa Garrett, Chief Public Health Nursing Officer and Deputy Director, Utah Department of Health One Wednesday shortly before the forum, Teresa Garrett, the chief public health nursing officer and deputy director at the Utah Department of Health, spent 8 hours in her car, 6 hours at an H1N1 mass vaccination clinic, 2 hours on e-mail, and 1 hour on a conference call while she was driving. She dealt with three telephone calls from reporters and two calls from concerned legislators about the new mammogram guidelines. She

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49 TESTIMONY walked 1,623 steps, drank four bottles of water, ate at McDonald’s, and took a nap at a rest stop for 20 minutes. Garrett said that her situation is not much different from those of her colleagues in public health nursing. “Our jobs are hard, challenging, and the experience of a lifetime.” Garrett’s greatest concern is the public health nursing shortage. In 1980, public health nurses represented 39 percent of the public health workforce. Today they are somewhere between 11 and 15 percent of that workforce, said Garrett. In a recent study, 30 of 37 states surveyed re- ported that the loss of public health nurses is their greatest concern in the deterioration of the public health system (Perlino, 2006). Public health nurses are the critical link in changing behaviors and improving the health of entire populations. They promote health, disease prevention, and social change and have a unique ability to reach across cultural di- vides. “These are the things that we will need in a truly reformed health system,” Garrett said. A variety of factors are contributing to the current public health nurs- ing shortage, including the aging population of nurses, poorly funded public health systems, limited advocacy for public health, a growing shortage of faculty who understand how to teach public health nursing, curricula that do not adequately cover public health or community nurs- ing, and the overall invisibility of public health nurses. To counter these trends, Garrett said that public health nurse leadership development needs to be nurtured, resources are required to rebuild the public health nursing infrastructure, and a new infrastructure is needed to provide in- terventions to vulnerable and at-risk populations that represent the weak- est link in the health care system. Tina Johnson, Director of Professional Practice & Health Policy American College of Nurse-Midwives The Maryland General Women’s Health Associates serves one of the most at-risk communities in the city of Baltimore, said Tina Johnson, director of professional practice and health policy for the American Col- lege of Nurse-Midwives, who serves as a certified nurse midwife for the group. Yet this obstetric service has the lowest cesarean section rate in all of Maryland, with “decreased morbidity and mortality and decreased costs to the health care system,” said Johnson. For many clients of the service, nurse midwives are the only health care providers they have encountered since childhood. They enter the

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50 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY service in desperate need of nutritional and exercise counseling, relation- ship and parenting skills, immunizations, dental care, mental health care, social services, smoking cessation, addiction services, and a wealth of other services, Johnson said. The women are encouraged to use the mid- wives’ 24-hour telephone triage system, which builds trust, enhances communication, and decreases emergency room visits and hospital stays. As women progress throughout pregnancy, labor, delivery, and the post- partum period, midwives are there “all along the way,” said Johnson, “diagnosing and treating their chronic and acute conditions, their asthma, bronchitis, skin rashes, and any infections that crop up, and managing their diabetes, preeclampsia, and many other health care needs.” If the women are able to continue with their care through the program, it can be continuous throughout their lifespan, though most are covered only dur- ing pregnancy. The nurse midwives at Maryland General also provide education and training for family practice residents at the University of Maryland. The residents work one on one with midwives in the labor and delivery unit, learning firsthand how to assess, evaluate, appropriately treat, and com- municate with clients. “The collaborative care model in place at this in- stitution requires a high degree of trust and respect among providers, with each team member providing care, perspective, and expertise. This philosophy is modeled for the residents, resulting in a broader knowledge base and an enhanced interdisciplinary educational experience,” said Johnson. Given the many advantages of this program, why aren’t more com- munities using collaborative midwife models for obstetric and primary care for women? Unfortunately, there are many barriers, Johnson said. The Maryland General Women’s Health Associates cannot readily col- lect the data needed to demonstrate adequately the effectiveness of its interventions because patients are admitted to the hospital under the name of the attending physician, not the name of the midwife. The group has not been able to convince the hospital administration to grant admit- ting privileges for certified nurse midwives, nor can they practice to the full scope of their licensure. For example, in the State of Maryland and many others, certified nurse midwives must have a signed collaborative agreement on file with the Board of Nursing to get a license. “This means essentially that you have to have a job before you can practice. You can’t get a license until you already have a job, and people have dif- ficulty starting practices or expanding services because of this.” Addi- tionally, midwives and other advanced practice nurses cannot be

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51 TESTIMONY equitably reimbursed for all services in all settings by Medicare and Medicaid and other payers. Nor can they be paid for their services train- ing residents or even their own midwifery students, because the slots available for midwifery and other nursing students are taken up by medi- cal residents for whom the institution is paid, said Johnson. “It is imperative that barriers to collaborative community care mod- els such as these across the country be removed once and for all so that improved access to high-value primary care is available to everyone,” Johnson concluded. Susan Apold, President New York State Association of Nurse Practitioners “The nation’s nurse practitioners stand ready to participate in the solution to the looming primary care crisis,” said Susan Apold, president of the New York State Association of Nurse Practitioners. A century ago, fewer than 10 percent of physicians held a bachelor’s degree, and the number one cause of death was infection. At that time the nation took a look at health care and made a conscious decision to change how it was done. A similar change is needed today, said Apold. The diagnosis and cure system that characterizes U.S. health care has become outdated. What is needed today is a prevention and management method of care. “There is more than enough work to go around for every health care pro- vider in this nation, if we model the health care system the way it needs to be modeled,” said Apold. For nurse practitioners to be part of the solution, barriers to practice must be eliminated. Apold said that when she gets on a plane in New York and flies to New Mexico, “I no longer need any regulation to practice—it is an amazing phenomenon.” The future of primary care de- pends on the full integration of all health care professionals practicing at the full scope of their licenses. Apold said that the regulation by states of nurse practitioners is not based on evidence or on best practices in primary care. In addition, the education of nurses and equitable reim- bursements need to be re-examined. “We cannot continue to throw money at a system that does not work. We must pay for performance,” concluded Apold.

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52 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY Pat Ford-Roegner, Chief Executive Officer American Academy of Nursing Evidence-based, nurse-led interventions can improve the health and psychological resilience of individuals, families, and communities, said Pat Ford-Roegner, CEO of the American Academy of Nursing (AAN). Three years ago the AAN helped initiate the Raise the Voice campaign to end the invisibility of nursing. One of the first actions by that campaign was to call for the full integration of mental health services into the health care delivery system. In particular, older Americans with co- existing depression, anxiety disorder, or dementia need appropriate nurs- ing care across all settings. “It is nurses who care for elders in long-term care, primary care, acute care settings, and the home.” Ford-Roegner said that all nurses must have the capacity and competence to handle the full range of needs of older adults. The AAN’s Geropsychiatric Nursing Collaborative is developing and disseminating core educational enhancements, curricula, and online guides for all nurses and all nursing programs. These resources will help nurses to care for and be able to recognize at least the basic mental health needs of the aging population, but this effort needs more funding and support to succeed across all practice and educational settings. For ad- vanced practice nurses who specialize in psychiatric nursing, barriers to practice must be removed, particularly in regard to prescription of medi- cation. In addition, much more needs to be done to work closer with mental health consumer organizations to reduce all barriers to the full integration of mental health and substance abuse services into primary care, concluded Ford-Roegner. Andrew Rosenzweig, Assistant Clinical Professor Brown University Medical School and Medical Director, MedOptions Some of the most challenging patients in long-term care are those with dementia, mental health disorders, and other behavioral health prob- lems, said Andrew Rosenzweig, assistant clinical professor at Brown University Medical School and medical director for MedOptions. These patients can contribute to high levels of staff turnover and can even be responsible for workplace violence, which occurs more frequently in nursing homes than in any other workplace setting.

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53 TESTIMONY MedOptions, which is the largest provider of behavioral health care services to long-term care facility residents in four states, uses nurse-led multidisciplinary teams of psychiatrists, psychologists, social workers, physician assistants, and others to deliver care. A focus of the effort is to educate and empower the nursing staff in the facilities, “who are para- mount to improving the quality of care of our patients and quality of life,” said Rosenzweig. This approach has been able to overcome many of the challenges of long-term care, including workplace stress, dissatis- faction, and overreliance on medications for management of behavioral problems. “Our clinical model is based on what actually works, as op- posed to what is easy to implement. We use behavioral management ap- proaches and not just purely pharmacological approaches. And we involve staff and family members in the treatment team. We don’t just focus on the resident. Instead [we] develop solid relationships with facil- ity staff based on trust, availability, and creative problem-solving skills,” said Rosenzweig. The results of this approach have included reductions in hospital ad- missions, fewer emergency room visits, improved staff and family satis- faction, and improved compliance and survey results. “Positive outcomes occur naturally,” Rosenzweig said. David Smith, Research Professor Drexel University School of Public Health A recent article in Health Affairs titled “The Accumulated Chal- lenges of Long-Term Care” (Smith and Feng, 2010) and a recent book titled The Forensic Case Studies: Diagnosing and Treating the Patholo- gies of the American Health System (Smith, 2009) both point out that the long-term care system now faces its most serious crisis of the past cen- tury, observed David Smith, research professor at the Drexel University School of Public Health’s Center for Health and Quality. In the next four decades, there will be a fourfold increase in the number of people need- ing long-term care. Of more concern, there will be a dramatic shift from inpatient nursing home settings to home- and community-based services. Nurses will be in the “hot seat,” said Smith, as this transition occurs. In particular, serious problems in terms of the quality of care can be ex- pected to occur repeatedly in the long-term care system. A way to ease this transition will be to move away from reliance on fee-for-service payments to models that have been pioneered in long-

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54 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY term care, such as the PACE (Program of All Inclusive Care for the Eld- erly) program and social health maintenance organizations, said Smith. In addition, the health care reform bill debated in Congress included pro- visions for people to purchase care in their own homes. Debra Wolf, Associate Professor Slippery Rock University The use of information technologies can lead to greatly improved outcomes for the quality and safety of health care delivered to aging populations, said Debra Wolf, associate professor at Slippery Rock Uni- versity. In one long-term care facility where the effects of innovative technology were documented, skin breakdowns in high-risk patients de- creased by 75 percent, nursing turnover decreased by 74 percent, and nursing assistant turnover decreased by 40 percent, said Wolf. The TIGER (Technology Informatics Guiding Education Reform) initiative depends on the need for nursing executives to envision and em- brace accelerated adoption of technology using standards-based, interop- erable technology that can support clinical decision making. Not only do such systems have the ability to stop drug-to-drug interactions or allergy- to-drug interactions, but they have the logic to alert nursing assistants to “not forget to turn Ms. Smith—she is at high risk. Don’t forget to toilet Mr. Smith—he needs it every two hours,” said Wolf. Nurses need to design these systems, not information technology staff who do not understand nursing processes, said Wolf. The TIGER initiative also believes that education reform in nursing programs is needed to develop a workforce that is capable of using technology. This education, whether delivered through two-year or four-year programs, needs to teach prospective nurses how to look at workplace logic, how to question it, and how to design it. “This is redefining what meaningful use really is,” said Wolf. “Nurses need to be actively involved at the na- tional level with health information technology—advancing, guiding, and leading.”

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55 TESTIMONY Gwen Foster, representing Juliet Santos of the International Council for Corporate Health The nation cannot afford today’s spiraling health care costs, so prevention is essential, said Gwen Foster, who was representing Juliet Santos, president of the International Council for Corporate Health. Nurses must be trained to mentor and provide skills to people so that they undertake their own personal health reform, regardless of their in- born predispositions. “Faulty genes might load the gun, but it is lifestyle that pulls the trigger,” said Foster. As an example, Foster cited a group of diabetics who were able to get their type 2 diabetes under control, despite a lack of health insurance and other resources. Nurse practitioners took the lead in home programs organized as health parties, where nurses in people’s home gave them the skills and motivation to change. Beyond prevention, nurses need to teach people to take personal re- sponsibility for their health. Foster uses what she calls the FACES model—fun, accountable, credible, empowering, and sustainable. “We have to get out of the notion of blaming everybody else,” she said. “We have to empower people and give them the skills so they can do it with us or without us.” Concluding Remarks At the end of the forum, moderator Josef Reum invited members of the audience to comment on ideas they had heard during the event or to add points that they had not heard. This final open-microphone session yielded many interesting observations from the audience. Like the testi- mony summarized above, these comments should not be interpreted as positions or recommendations of the committee, the Robert Wood John- son Foundation, or the Institute of Medicine. The section below includes a summary of the remarks that were offered by members of the audience at the forum: • Public health nurses have important roles to play in advancing health policy no matter what the setting—in front of a school board, in their communities, in the state legislature, or at the fed- eral level. • Education programs will never be able to fully prepare future nurses for all the roles they must fill, which means that programs

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56 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY for new nurses are essential, especially programs that connect novice nurses with experienced mentors in community settings, said one forum participant. • Nursing needs to reflect the diversity of society, which will re- quire that nurses from diverse populations assume leadership roles, said a member of the audience. These leaders could help recruit, retain, and promote the next generation of nurses. The audience member noted that there needs to be better communica- tion between community health nurses and nurses in academia about the importance of nurses’ roles in maintaining health, no matter the setting in which a nurse works. • On a global scale, more than two-thirds of the world’s popula- tion is not white. Issues of disparities, diversity, and inequities are prevalent in the United States, but the face of nursing in the United States does not reflect the global reality, said one forum participant. U.S. nursing should be seen in a global context, where the majority of nurses are nonwhite. • Nurses need to be leaders in the shift of the health care system from an emphasis on diagnosis and treatment to an emphasis on wellness and prevention, suggested another member of the audi- ence. With their specialized skills and perspectives, nurses are well positioned to help the health care system make this transi- tion. Yet nursing education is today heavily focused on acute medical care, which requires changes in the curriculum to pre- pare nurses for a different kind of future. • The health care system today is fragmented and based on pay- ment models. One individual envisioned a project to build a con- tinuous model of care that could start in 12 communities and could then lead the way to changes on a much broader scale. In such a model, nurses in different parts of the health care system, such as acute care nurses and public health nurses, would work together to ensure seamless transitions for health care recipients. • U.S. nursing homes are in an emergency situation, said one fo- rum participant. The majority of residents in these facilities are experiencing an absence of professional nursing care; there are not enough nurses employed in nursing homes, so the average resident receives just a half an hour a day of care from a regis- tered nurse. The federal and state governments generally require limited coverage of nursing homes by registered nurses, and these nurses are paid significantly less than their colleagues in

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57 TESTIMONY hospitals, which creates serious recruitment and retention chal- lenges. The participant offered a number suggestions for the committee to consider, including the following: The number of registered nurses in nursing homes should o increase; Nurses should be able to provide health assessments and care o management to residents while ensuring safe supervision of the unlicensed staff, who provide the majority of care; There should be adequate proportions of federal and state o funding to pay for the care of residents in nursing homes, and funding should be targeted to nurse staffing and to ade- quate compensation for registered nurses; and A national campaign should be launched to recruit future o nurses into careers of caring for older adults. • For nurses and other health care professionals to deliver the best possible care, they need access to information about evidence- based interventions, said a member of the audience. Nurses therefore need to be prepared to use information technologies to access the information that will drive health care in the future. • Nurses need to be able to cross institutional boundaries to pre- vent the “siloing” that is so prevalent in health care. A nurse practitioner should be able to run a clinic in a school while also being the school nurse and proving opportunities for students with diverse backgrounds to become interested in nursing, said one forum participant. • A profile of nursing needs to be done in different settings, look- ing at age, retirement plans, expertise, leadership, the potential for nurses to move from one setting to another, and so on, sug- gested one individual. • A television show about nursing could demonstrate the full di- versity of what nurses offer, particularly in creating collaboration across disciplines, said one participant. Similarly, the participant said that the President’s cabinet should not be considered com- plete unless there is a nurse at the table. • Nurses and other health care providers who want to work in the community need to put aside stigma and social distinctions and create a new model of training that deviates from the past em- phasis on acute illness, said another member of the audience.

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58 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY • Many physicians are frustrated because they lack the skills to be effective in the community, said one forum participant. Nurses could forge a partnership with physicians around the need for a common set of training experiences that will permit both groups of professions to meet the challenges of community- based medicine. • Education models must foster creativity, empowerment, and leadership if nurses are to make the changes needed for better health of everyone in a community, concluded another participant.