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2
Study Context
This chapter presents essential context for the remainder of the report, addressing in turn the evolving challenges faced by the health care system, which drive the need for a reformed system and the concomitant transformation of the nursing profession; the three primary concerns targeted by health care reform—quality, access, and value; and the principles the committee determined must guide any reform efforts. The final section summarizes the committee’s conclusions about the implications of this discussion for the role of nurses in transforming the health care system.
EVOLVING HEALTH CARE CHALLENGES
For decades, the major focus of the U.S. health care system has been on treating acute illnesses and injuries, the predominant health challenges of the early 20th century. In the 21st century, the health challenges facing the nation have shifted dramatically:
Chronic conditions—While acute injuries and illnesses will never disappear, most health care today relates to chronic conditions, such as diabetes, hypertension, arthritis, cardiovascular disease, and mental health conditions, which in 2005 affected nearly one of every two Americans (CDC, 2010). This shift can be traced in part to the increased capabilities of the health care system to treat these conditions and in part to the
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health challenges of an aging population, as the prevalence1 of chronic conditions increases with age. Dramatic increases in the prevalence of many of these conditions since 1970 are expected to continue (DeVol et al., 2007). Increasing obesity levels in the United States have compounded the problem, as obesity is related to many chronic conditions.
An aging population—According to the most recent census projections, the proportion of the U.S. population aged 65 or older is expected to rise from 12.7 percent in 2008 to 19.3 percent in 2030 (U.S. Census Bureau, 2008), in part as a result of increases in life expectancy and the aging of the Baby Boom generation. As the population continues to age, a dramatic growth in demand for health care services will be seen (IOM, 2008).
A more diverse population—Minority groups, which currently make up about a third of the U.S. population, are projected to become the majority by 2042 and 54 percent of the total population by 2050 (U.S. Census Bureau, 2008). Diversity exists not only among but also within various ethnic and racial groups with respect to country of origin, primary language, immigrant status and generation, socioeconomic status, history, and other cultural features.
Health disparities—Health disparities are inequities in the burden of disease, injury, or death experienced by socially disadvantaged groups relative to either whites or the general population. Such groups may be categorized by race, ethnicity, gender, sexual orientation, and/or income. Health disparities among these groups are driven in part by deleterious socioenvironmental conditions and behavioral risk factors, and in part by systematic biases that often result in unequal, inferior treatment (IOM, 2003b).
Limited English proficiency—The number of people living in the United States with limited English proficiency is increasing (U.S. Census Bureau, 2003). To be effective, care and health information must be accessible and offered in a manner that is understandable, as well as culturally relevant (IOM, 2004a; Joint Commission, 2007). While there are national standards for linguistically and culturally relevant health care services, the rapid growth of diverse populations with limited English proficiency and varying cultural and health practices is emerging as an increasingly complex challenge that few health care providers and organizations are currently prepared to handle (HHS Office of Minority Health, 2007).
1
Prevalence defines the total number of individuals with a condition, and incidence refers to the number of new cases reported in a given year.
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PRIMARY CONCERNS IN HEALTH CARE REFORM: QUALITY, ACCESS, AND VALUE
In the search for solutions to improve the health care system, experts target three primary concerns: quality, access, and cost or value (Goldman and McGlynn, 2005). Substantial reforms designed to reshape and realign the major features of the entire health care system are needed to redress deficiencies in these three areas.
Quality
Despite unsustainable growth in health care spending in the United States (discussed below), the care received by individuals can often be too much, too little, too late, or too haphazard. Moreover, substantial geographic variations exist in the intensity of care provided across the nation, with attendant differences in quality, as well as cost (Fisher et al., 2009). The quality improvement movement in health care has grown significantly since the publication of two IOM reports: To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2000, 2001). These reports helped shift discussions about quality away from assigning all responsibility and accountability to individual health professionals. They showed that improving quality requires an understanding of how such elements as systems and processes of care, equipment design, and organizational structure can fundamentally enhance or detract from the quality of care. Researchers also have emphasized the importance of building interprofessional teams and establishing collaborative cultures to identify and sustain continuous improvements in the quality of care (Kim et al., 2010; Knaus et al., 1986; Pronovost et al., 2008).
Access
Although the Affordable Care Act (ACA) provides insurance coverage for an additional 32 million Americans, millions of Americans will still lack coverage in 2019 (CBO, 2010). Even for those with insurance, out-of-pocket expenses, such as deductibles and copays, as well as limited coverage for necessary services and medications, create financial burdens that can limit access to care (Doty et al., 2005; Himmelstein et al., 2009). Other significant barriers to access include a lack of providers who are accepting new patients, especially those covered by Medicaid; a lack of providers who offer appointments outside of typical business hours; and for some a lack of transportation to and from appointments. Also hindering access is the above-discussed rapid growth of populations with limited English proficiency (U.S. Census Bureau, 2010), as well as limited health literacy among fluent English speakers.
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Value
The term “value” has different meanings in different contexts. For the purposes of this report, the committee uses the following definition: “value in health care is expressed as the physical health and sense of well-being achieved relative to the cost” (IOM Roundtable on Evidence-Based Medicine, 2008). As one of the major components of value—quality—is discussed above, this section focuses on cost.
The United States spends more than any other nation—16.2 percent of gross domestic product in 2008—on health care (CMS, 2010a). Yet this investment is not matched by superlative health care outcomes (OECD, 2010), indicating deficiencies in the value of some aspects of the health care system. Moreover, while the United States spends too much on certain aspects of health care, such as hospital services and diagnostic tests, spending on other aspects is disproportionately low. For example, public health represents less than 3 percent of health care spending (CMS, 2010b).
Health care spending is responsible for large, and ultimately unsustainable, structural deficits in the federal budget (Dodaro, 2008), and many economists believe that rising health care costs are a principal reason why wages have increased so little in recent years (Emanuel and Fuchs, 2008). However, establishing and sustaining legislated cost controls and health care savings has proven elusive. Challenges with regard to costs and spending make achieving value within the health care system difficult.
Throughout its deliberations, the committee found it useful to focus on ensuring that the health care system delivers good value rather than focusing solely on cost. Accordingly, the committee paid particular attention to high-value innovations in nursing care that provide quality, patient-centered care at a lower price. Three specific examples are featured as case studies later in this chapter.
PRINCIPLES FOR CHANGE
The challenges faced by the U.S. health care system have been described and documented in recent years by many government agencies, researchers, policy analysts, and health professionals. From this work, a consensus has begun to emerge regarding some of the fundamental principles that should guide changes to meet these challenges. Broadly, the consensus is that care in the United States must become more patient centered; primary care and prevention must play a greater role relative to specialty care; care must be delivered more often within the community setting and even in people’s homes; and care needs to be coordinated and provided seamlessly across health conditions, settings, and providers. It is also important that all providers practice to the fullest extent allowed by their education, training, and competencies and collaborate so that improvements can be achieved in both their own and each other’s performance. This section pro-
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vides an overview of these shifts in thinking and practice that a growing number of health care experts believe should be at the core of any proposed health care solutions.
The Need for Patient-Centered Care
Health care research is demonstrating the benefits of reorganizing the delivery of health care services around what makes the most sense for patients (Delbanco et al., 2001; Hibbard, 2004; Sepucha et al., 2004). As outlined in Crossing the Quality Chasm, patient-centered care is built on the principle that individuals should be the final arbiters in deciding what type of treatment and care they receive (IOM, 2001). Yet practice still is usually organized around what is most convenient for the provider, the payer, or the health care organization and not for the patient. Patients are repeatedly asked, for example, to change their expectations and schedules to fit the needs of the system. They are required to provide the same information to multiple caregivers or in sequential visits to the same provider. Primary care appointments typically are not available outside of work hours. The counseling, education, and coaching needed to help patients make informed decisions have historically been given insufficient attention (Hibbard, 2004). Additionally, patients’ insurance policies often limit their choice of provider, especially if the provider is not a physician (Craven and Ober, 2009). Box 2-1 presents an example of how one health system, the University of Pittsburgh Medical Center, has implemented a truly patient-centered program.
How Patient-Centered Care Improves Quality, Access, and Value
A number of studies have linked patient-centered and quality care (Sepucha et al., 2004). For example, studies that compared surgery with watchful waiting for patients with benign prostatic hyperplasia showed how strong a role patient preference played in determining quality of life (Barry et al., 1988; Fowler et al., 1988; Wennberg et al., 1988). Likewise, involving patients more directly in the management of their own condition was found to result in significant improvements in health outcomes for individuals with insulin-dependent diabetes mellitus (Diabetes Control and Complications Trial Research Group, 1993). By 2001, so many different studies had found similar results that Crossing the Quality Chasm identified patient-centered care as one of six pillars on which a 21st-century health care system should be built (the others being safety, effectiveness, timeliness, efficiency, and equity) (IOM, 2001).
One of the hallmarks of patient-centered care is improving access to care, a key component of which is access to information. For example, a growing number of patients have greater access to their own laboratory results and diagnostic writeups about their procedures through such electronic forums as personal health records and patient portals. Many people participate in online communities to
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BOX 2-1
Case Study: When Patients and Families Call a Code
The University of Pittsburgh Medical Center Is Transforming Care at the Bedside
In 2001, 18-month-old Josie King was hospitalized at Johns Hopkins Children’s Center with burns she had sustained in a bathtub accident. Josie responded well to treatment at first, but her condition quickly deteriorated. When her mother, Sorrel King, expressed concern, the staff nurses and physicians repeatedly dismissed them, and 2 days before her scheduled discharge Josie died. The cause was dehydration and a wrongly administered opioid—the result of a series of errors the hospital acknowledged.
Ms. King has since devoted herself to the elimination of medical errors, founding the Josie King Foundation (www.josieking.org) and addressing clinicians, policy makers, and consumers on the importance of creating a “culture of safety.” And the need is pressing. According to a 2000 Institute of Medicine report, up to 98,000 people die from medical errors each year (IOM, 2000); nearly 10 years after that report’s publication, despite improved patient-safety systems, a 2009 report gave a grade of C+ to efforts to empower patients to prevent errors (Wachter, 2009).
Tami Minnier, MSN, RN, FACHE, heard Ms. King speak in 2005, and the message was clear: if the staff had listened to her mother’s concerns, Josie would have lived. “When I came back to work the following Monday,” said Ms. Minnier, at the time chief nursing officer at the University of Pittsburgh Medical Center (UPMC) at Shadyside, “I told my chief medical officer, ‘We’re going to let patients and families call a rapid-response team’—a group of staff who are designated by the hospital to respond immediately to other staff’s requests for help with critical or emergency patient situations. He thought I was insane.”
As we’ve always known, when you give power and authority to patients, they treat it with great respect.
—Tami Minnier, MSN, RN, FACHE, chief quality officer, University of Pittsburgh Medical Center
Shadyside had been one of the first three hospitals to participate in Transforming Care at the Bedside (TCAB), an initiative of the Institute for Healthcare Improvement (IHI) and the Robert Wood Johnson Foundation, enabling front-line nurses to test their ideas for improving the safety and quality of care. Ms. Minnier called on Sorrel King to work with the nurses in Shadyside’s TCAB unit in creating what they called Condition H (or Condition Help). They interviewed patients and families about when and why they might call for a rapid-response team, consisting of a nurse administrator, a physician, a staff nurse, and a patient advocate who would convene immediately in response to a patient’s or visitor’s call. They held drills with staff, and within
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6 months, Condition H went live in the hospital’s TCAB unit.
While some staff feared that patients would abuse the hotline, that concern was not borne out. Today, patients and families throughout UPMC’s 13 acute care hospitals can use Condition H. They receive information on how to make the call (dial 3131 and say, “Condition H”) during admission and through posters, a video, and stickers placed on patients’ phones.
Ms. Minnier is now chief quality officer at UPMC and monitors the use of Condition H. At Shadyside, a 500-bed hospital, two or three calls are made each month, and only a few patients have called twice during the same admission. An analysis of the 45 calls made in the first 17 months showed that inadequately managed pain was the most frequent impetus for calls, and more than 60 percent of the calls led to interventions that were deemed instrumental in preventing a patient-safety event.
Condition H is spreading and serves as one example of the changes hospitals have adopted using TCAB methods. Reports on TCAB have shown that it generates improved outcomes, greater patient and family satisfaction, and reduced turnover of nurses (Hassmiller and Bolton, 2009).
Sorrel King addressed medical and nursing students at an IHI-sponsored event in 2009 and spoke strongly in favor of Condition H. “Had I been able to push a button for a rapid-response team, that team would have come, they would have assessed Josie and … said one thing: the child is thirsty,” Ms. King said. “They would have given her a drink, and she never would have died” (Matthews, 2009).
Information about Condition H is clearly posted throughout UPMC at Shadyside, on patients’ televisions, bulletin boards, and telephones.
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learn more about or even how to manage their own conditions. Improving access also requires delivering care in a culturally relevant and appropriate manner so that patients can contribute positively to their own care.
Fewer studies have examined the economic value of patient-centered care. One such study found that offering a nurse advice phone number and a pediatric after-hours clinic resulted in a 17 percent decrease in emergency department visits (Wilson, 2005). Yet there is no reason to believe that enhancing patient-centered care will or even should always lead to lower costs. For example, truly patient-centered approaches to care may require new programs or additional services that go beyond current standards of practice.
Nurses and Patient-Centered Care
Nurses have long emphasized patient-centered care. The case study in Box 2-2 provides but one example—the patient-centered approach of midwifery care at the Family Health and Birth Center (FHBC) in Washington, DC. Through the FHBC, mothers-to-be who often have little control over their own lives develop a sense of control over one very important part of their lives. From such modest beginnings, many more hopeful futures have been launched.
The Need for Stronger Primary Care Services
Consensus is also strong on the need to make primary (rather than specialty) care a greater part of the health care system. Despite steps taken by the ACA to support the provision of primary care, however, the shortage of primary care providers is projected to worsen in the United States in the coming years (Bodenheimer and Pham, 2010; Doherty, 2010).
Primary care has been described in many ways. The IOM has defined it as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996). Starfield and colleagues identify the functions of primary care as “first-contact access for each new need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere” (Starfield et al., 2005). Similarly, the Government Accountability Office (GAO) has cited the following hallmarks of primary care: preventive care, care coordination for chronic illnesses, and continuity of care (Steinwald, 2008). Thus primary care is closely tied to two of the principles for change discussed below—the need to deliver more care in the community and the need for seamless, coordinated care.
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How Primary Care Improves Quality, Access, and Value
Countries that build their health care systems on the cornerstone of primary care have better health outcomes and more equitable access to care than those that do not (Starfield et al., 2005). However, primary care plays a less central role in the U.S. health care system than many health policy experts believe it should (Bodenheimer, 2006; Cronenwett and Dzau, 2010; IOM, 1996; Starfield et al., 2005; Steinwald, 2008). Geographic variations nationwide illustrate the importance of primary care. Regions of the United States with a higher ratio of generalists to specialists provide more effective care at lower cost (Baicker and Chandra, 2004), and studies have shown that those states with a greater ratio of primary care providers to the general population experience lower mortality rates for all causes of death (Shi, 1992, 1994). The positive effect is more pronounced among African Americans who have access to primary care than among whites, thus indicating that this is a promising approach to decreasing health disparities (Starfield et al., 2005). Yet primary care services have been so difficult to access in parts of the United States that one in five adults has sought nonurgent care at an emergency department (IOM, 2009).
Nurses and Primary Care
Nurses with varying levels of education and preparation play important roles in primary care. Health promotion, education, and assessment are essential components of primary care that are also traditional strengths of the nursing profession; these services may be provided by either registered nurses (RNs) or advanced practice registered nurses (APRNs). RNs provide primary care services across the spectrum of health care settings—from acute care to home care to public health and community care. As visiting or home health nurses, RNs are positioned to identify new health problems or needs, such as medication education, prevention services, or nutrition counseling. In public health clinics, they may provide community assessments, developmental screenings, or disease surveillance. RNs in acute care settings may identify new health care problems and needs as they care for patients and their families. The range of possibilities for RNs providing primary care is significant, and their capacity for filling these roles is not always recognized.
APRNs, especially nurse practitioners (NPs), also provide primary care services across all levels of the health care system. In many situations, NPs provide care that is comparable in scope to that provided by primary care physicians. As discussed in Chapter 3, in many situations, APRNs are qualified to diagnose potential and actual health problems, develop treatment plans, in some case
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BOX 2-2
Case Study: Nurse Midwives and Birth Centers
The Midwifery Model of Maternity Care Gives Mothers Control and Improves Outcomes
When Wendy Pugh delivered her first child at age 30 in a Washington, DC, hospital in 1999, her labor was induced—not out of medical necessity, she said, but because “there was a scheduling issue with the doctor.” She didn’t question the obstetrician’s decision at the time, but when she got pregnant again, she polled her friends and discovered that many had had cesarean sections. When she asked why, few gave medical reasons. She decided she wanted “a more organic process.”
Midwifery teaches you that the woman is the most important person in the relationship and that’s why you should listen to her and try to give her what she wants and what she needs.
—Ruth Watson Lubic, EdD, CNM, FAAN, founder, Family Health and Birth Center
Seven months into her second pregnancy, Ms. Pugh arrived at the Family Health and Birth Center (FHBC) in northeast Washington, DC (www.yourfhbc.org), where certified nurse midwives provide pre- and postnatal care and assist with labor and delivery with little technological intervention. Delivery takes place at a homelike freestanding birth center or at a nearby hospital, depending on the woman’s choice, her health, and such factors as whether she is homeless. The FHBC accepts Medicaid and private insurance and offers a sliding-scale fee for those ineligible for Medicaid. No one is turned away.
Ruth Watson Lubic, EdD, CNM, opened the FHBC in 2000 in response to the disproportionately high rates of infant and maternal death, cesarean section, and premature birth among poor and minority women in Washington, DC. In 2009 the infant mortality rate in the city was 12.22 per 1,000 live births, far exceeding that of any state in the nation (Heron et al., 2007). Nationwide, nearly four times as many black as white infants die as a result of premature birth or low birth weight (HRSA, 2006). Dr. Lubic had already founded the first freestanding birth center in the country (in 1975 in New York City) and
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has dedicated her career to reducing disparities in birth outcomes. “We’re hoping to serve as a model for the whole country,” Dr. Lubic said. There are now 195 such centers in the United States.
A pregnant woman receives prenatal care at the Family Health and Birth Center.
Ms. Pugh’s case highlights the differences between the midwifery model of care, which promotes maternal and infant health, and the obstetrics model, which anticipates complications. During the hospital delivery of her first child, Ms. Pugh received pitocin to induce labor, saw her newborn for just a few moments before the child was taken away, and did not breastfeed until the second day. In contrast, during the delivery of her third child—her second delivery at the FHBC—she received assistance during labor from a doula, a trained volunteer who provided coaching and massage; her newborn was placed on her chest immediately after the birth; mother and child went home within hours of delivery; and when the infant showed difficulties with breastfeeding, a peer lactation counselor went to their home.
Two systematic reviews have found that women given midwifery care are more likely to have shorter labors, spontaneous vaginal births without hospitalization, less perineal trauma, higher breastfeeding rates, and greater satisfaction with their births (Hatem et al., 2008; Hodnett et al., 2007). Unpublished FHBC data show that, compared with all African American women giving birth in Washington, DC, women giving birth at the center have almost half the rate of cesarean sections, onethird the rate of births at less than 37 weeks’ gestation, and half the rate of low-birth-weight newborns. The lower rates of complications added up to an estimated $1,231,000 in savings in 2005—more than the cost of operating the center that year. The FHBC reports a 100 percent breastfeeding rate among women giving birth at the center.
Obstacles to widespread use of the FHBC model include the fact that
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Recurrent patterns of success included actively engaged nurses supported in standardizing their own processes of care according to the IHI bundles and empowered and supported in monitoring and enforcing those standards across disciplines, including with their physician colleagues (Berwick et al., 2006). Encouraged to innovate locally to adapt changes to local contexts, nurses proved the ideal leaders for changing care systems and raising the bar on results.
One new role for nurses that taps their potential as innovators is the clinical nurse leader (CNL), an advanced generalist clinician role designed to improve clinical and cost outcomes for specific groups of patients. Responsible for coordinating care and in some cases actively providing direct care in complex situations, the CNL has the responsibility for translating and applying research findings to design, implement, and evaluate care plans for patients (AACN, 2007). This new role has been adopted by the VA system.
The Need for Interprofessional Collaboration
The need for greater interprofessional collaboration has been emphasized since the 1970s. Studies have documented, for example, the extent to which poor communication and lack of respect between physicians and nurses lead to harmful outcomes for patients (Rosenstein and O’Daniel, 2005; Zwarenstein et al., 2009). Conversely, a growing body of evidence links effective teams to better patient outcomes and more efficient use of resources (Bosch et al., 2009; Lemieux-Charles and McGuire, 2006; Zwarenstein et al., 2009), while good working relationships between physicians and nurses have been cited as a factor in improving the retention of nurses in hospitals (Kovner et al., 2007). As the delivery of care becomes more complex across a wide range of settings, and the need to coordinate care among multiple providers becomes ever more important, developing well-functioning teams becomes a crucial objective throughout the health care system.
Differing professional perspectives—with attendant differences in training and philosophy—can be beneficial. Nurses are taught to treat the patient not only from a disease management perspective but also from psychosocial, spiritual, and family and community perspectives. Physicians are experts in physiology, disease pathways, and treatment. Social workers are trained in family dynamics. Occupational and physical therapists focus on improving the patient’s functional capacity. Licensed practical nurses provide a deeply ground-level perspective, given their routine of measuring vital signs and assisting patients in feeding, bathing, and movement. All these perspectives can enhance patients’ well-being—provided the various professionals keep the patient and family at the center of their attention.
Finding the right balance of skills and professional expertise is important under the best of circumstances; in a time of increasing financial constraints, personnel shortages, and the growing need to provide care across multiple settings, it is crucial. Care teams need to make the best use of each member’s education,
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BOX 2-7
Case Study: The Nurse–Family Partnership
Nurses Visit the Homes of First-Time At-Risk Mothers, and the Results Are Wide-Ranging
In 2007 Crystalon Rodrigue, a recent high school graduate living in St. James, Louisiana, had an adverse reaction to an injectable contraceptive. She discontinued it and soon got pregnant. She was 19 years old and unemployed and living with her mother, and her relationship with her boyfriend was faltering. She turned to the state department of health; was referred to the Nurse–Family Partnership (NFP); and met “Miss Tina,” a nurse who visited her at home.
“In the beginning of my pregnancy, and maybe all throughout, I was a little stressed out,” the 21-year-old Ms. Rodrigue said recently. “I was depressed because I was having relationship problems with my child’s father. Miss Tina helped me….” Ms. Rodrigue was interrupted by the chatter of her 19-month-old daughter, Nalayia, who was learning to read, her mother said with pride. Then she continued, “Miss Tina helped me to think about myself.”
It was a quiet, almost offhand remark, but it represents the kind of shift in attitude that the NFP has helped foster among young women for more than 30 years. Now active in 375 counties in 29 states, the NFP sends registered nurses (RNs), usually with baccalaureate degrees, into the homes of at-risk, low-income, firsttime mothers for 64 planned visits over the course of a pregnancy and the child’s first 2 years.
When [the Nurse–Family Partnership nurse] came along, I was really down and out. I wouldn’t get out of the house at all. She’s helped me to be strong, to know that I can actually make it by myself and be a very good mom.
—Crystalon Rodrigue, 21-year-old Louisiana client of the Nurse–Family Partnership
Improving the lives of children is the chief aim of the NFP, yet the interventions target mothers. The
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nurse discusses options for the mother’s continued education and economic self-sufficiency; supports her in reducing or quitting smoking or drinking; teaches her about child development, nonviolent discipline, and breastfeeding; and helps her make decisions about family planning. The nurse does this by engaging the mother in a relationship that provides a model for interactions with others. The child’s father and other family members are encouraged to participate.
“We don’t look for the great big change,” said Luwana Marts, BSN,
Tina Becnel, a nurse who provides home visits, helped Crystalon Rodrigue during her pregnancy and continued through her daughter Nalayia’s second birthday.
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RN, regional nurse consultant for the NFP in Louisiana. “A part of the model is that only a small change is necessary. So if a client never quits smoking but she doesn’t smoke in the presence of her child, that’s a plus.”
In case-controlled, longitudinal trials conducted among racially and ethnically diverse populations—beginning in 1977 in Elmira, New York, and continuing in Memphis, Tennessee, and Denver, Colorado—the NFP has shown reductions in unintended second pregnancies and increases in mothers’ employment. Children of mothers visited by nurses are less likely to be abused and by age 15 to be arrested. (For links to these and other studies of the NFP, visit www.nursefamilypartnership.org/provenresults/published-research.) The per-child cost is $9,118; for the highest-risk children, a return of $5.70 per dollar spent is realized (Karoly et al., 2005).
Several models of home visitation are in use, but the NFP relies on trained RNs for its interventions. A 2002 study compared home visits by untrained “paraprofessionals” and nurses. On almost all measures, the nurses produced far stronger outcomes (Olds et al., 2002). “People trust nurses,” said Ruth A. O’Brien, PhD, RN, FAAN, professor of nursing at the University of Colorado in Denver and an author of the study. “Low-income, minority people who have not had a lot of trust in the health care system might be willing to let a nurse in the door.”
Barriers to implementation include the fact that states use various sources to fund the NFP, and in some the funding is limited. The Affordable Care Act mandates that $1.5 billion be spent over 5 years on home visitation programs for at-risk mothers and infants*—substantially less than the $8.5 billion over 10 years that President Obama requested in his 2010 budget (OMB, 2010). While the act establishes a federal agency to oversee such home visitation programs, it does not specify that nurses provide the care. Also, some municipalities increase the nurse’s caseload beyond the recommended 25, diminishing the intensity and effectiveness of the interventions.
For her part, Ms. Rodrigue is looking ahead. She had completed a certified nursing assistant program while pregnant and will soon start nursing school, in which she had enrolled but quit shortly after high school. “I wasn’t ready for it,” she said. “But now I have a child and I know what to expect. I feel like I’m ready. I want to better myself.”
*Patient Protection and Affordable Care Act, HR 3590 § 2951, 111th Congress.
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skill, and expertise, and all health professionals need to practice to the full extent of their license and education. Where the competency and skills of doctors and nurses safely overlap, it makes sense to rely on nurses to provide many of those services. Similarly, where the competency and skills of RNs and licensed practical or vocational nurses safely overlap, it makes sense to rely on the latter—or as the case may be, nurses’ aides—to provide many of those services. In this way, more specialized skills and competencies are appropriately reserved for the most complex needs. This type of skill balancing should not, however, be used as a means of cutting costs by indiscriminately replacing more skilled with less skilled clinicians.
CONCLUSION
Nurses are well positioned to help meet the evolving needs of the health care system. They have vital roles to play in achieving patient-centered care; strengthening primary care services; delivering more care in the community; and providing seamless, coordinated care. They also can take on reconceptualized roles as health care coaches and system innovators. In all of these ways, nurses can contribute to a reformed health care system that provides safe, patient-centered, accessible, affordable care. Their ability to make these contributions, however, will depend on a transformation of nursing practice, education, and leadership, as discussed in Chapters 3, 4, and 5, respectively. Nurses must remodel the way they practice and make clinical decisions. They must rethink the ways in which they teach nurses how to care for people. They must rise to the challenge of providing leadership in rapidly changing care settings and in an evolving health care system. In short, nurses must expand their vision of what it means to be a nursing professional. At the same time, society must amend outdated regulations, attitudes, policies, and habits that unnecessarily restrict the innovative contributions the nursing profession can bring to health care.
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