Community and Public Health
NURSING IN THE COMMUNITY
Carol Raphael, president and CEO of the Visiting Nurse Service of New York (VNSNY), described the work of VNSNY, its nursing workforce, and how technology is used to support its workforce. VNSNY is the largest nonprofit home health care agency in the United States; it was founded in 1893 by Lillian Wald and serves all five boroughs of New York City plus Westchester and Nassau counties. Every day VNSNY provides a range of services to a case population of approximately 30,000, from newborns to seniors, and about 2,600 nurses are among its 14,000 employees.
The VNSNY has a complex patient population to whom it provides a wide range of programs and services. These programs and services fall roughly into three categories. The first category is preventive care, including care provided for patients in congregate care facilities.1 The second category is home-based care, including post-acute care, long-term care, and hospice and palliative care. The VNSNY also functions as a health plan payer through a Medicaid Managed Long-Term Care program and through a Medicare Advantage Special Needs Plan.
Raphael described the average patients that VNSNY serves. The most common diagnoses among VNSNY’s patients are chronic conditions, including diabetes, hypertension, and congestive heart failure
(CHF). These diagnoses occur with an average of four other conditions; some common co-occurring diagnoses are CHF and chronic obstructive pulmonary disease (COPD); CHF and diabetes; and hypertension and dementia. On average, patients take eight different medications. About 9 percent have cognitive impairments, and 16 percent have a history of diagnosed depression or self-reported symptoms of depression—a figure that is likely an underestimate of the true proportion of cases suffering from depression. They usually have impairments in five to six ADLs (activities of daily living). About 50 to 75 percent of patients are from minority groups, and at least 36 different languages are spoken across VNSNY’s patient population.
The nurses who provide care through the VNSNY “have to do it all,” said Raphael. “They are the admissions office. They have to do the financial eligibility. We say, ‘When we walk into a home, we walk into a life.’ Our second major reason for worker’s compensation claims among our nurses is dog bites.2 You never know what you are going to face when you walk into someone’s home.”
The role of the VNSNY nurse varies depending on the setting and the needs of the patients. In congregate care, the role of the onsite nurse is threefold:
To conduct health promotion and education activities for residents, families, and building staff.
To provide case management for residents who need ongoing support for chronic conditions and to provide linkages to community resources.
To screen, assess, and link residents to home health care as needed.
For home care patients, the coordination of interdisciplinary care is a critical function of visiting nurses. They help patients recover and regain functioning, learn to manage their own conditions, avoid exacerbations in chronic conditions, and build up strength and endurance. This can encompass a wide range of nursing roles. Nurses may assess needs, the home environment, and financial coverage; develop and implement a plan of care; facilitate communication between and among providers and patients; document progress; manage medications; monitor for declines;
intervene before crises; and establish appropriate follow-up care or transfers to a different program.
Raphael cited examples of transitional care models developed by Mary Naylor, director of NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and Eric Coleman, professor of medicine at the University of Colorado. Using these models, nurses ensure that appropriate steps have occurred within the first 30 days of home care, a critical period of time when 16 percent of home health episodes result in hospitalization (Meadow, 2007). Following discharge, as many as 34 percent of patients may return to the hospital within 90 days of discharge, as a recent study involving Medicare fee-for-service patients found (Jencks et al., 2009). Nurses using transitional care models evaluate the risk of rehospitalization, develop emergency response plans, reconcile and simplify medications, make follow-up appointments with community providers, and plan for discharge from home care. Patients have an “action plan” that sets goals and responsibilities. This plan is posted in the home so that the patient will call VNSNY rather than 9-1-1 when there is a problem. In the 2 years since VNSNY started implementing transitional care, the rehospitalization rate of home care patients dropped from 27 percent to 23.5 percent, said Raphael.
VNSNY also operates a Nurse-Family Partnership program, such as the one described by Mary Selecky in Chapter 2, that ensures prenatal care; educates prospective parents about newborn care; fosters the physical, emotional, and cognitive development of children; and links families to other community supports and programs. The Father’s First program has been interlaced with the Nurse-Family Partnership to promote the increased involvement of fathers in parenting.
VNSNY operates two health plans programs specific to Medicaid and Medicare populations. In the Medicaid Managed Long-Term Care plan, nurses support plan members in the community, help to avoid nursing home stays, and manage members across settings. In the Medicare Advantage Special Needs Plan, nurses help members avoid preventable hospital and emergency room visits by ensuring the provision of primary care and by addressing service gaps. Special attention, including increased follow-up and additional communication and case management, is focused on the 15 percent of patients who are considered highest risk. “So far we are seeing considerable success,” said Raphael. “We devote a far lower portion of our premium to in-patient hospital stays than comparable Medicare Advantage plans do.”
Technology Supports for Nurses
Technology is a central component of VNSNY operations, said Raphael. All of its clinicians use laptops equipped with proprietary structured electronic health records. The clinician synchronizes the laptop with the VNSNY network from the field and is able to retrieve current data at the point of care. The technology was adapted by studying systems for mobile workforces, such as those used by Federal Express and other field-based organizations. “It is inconceivable that we could function without this system, which was further designed and developed by our nurses,” said Raphael. The technology has been universally adopted by the staff, so much so that any interruptions in service generate an immediate reaction.
Information in the mobile system is evidence-based, which forces providers to think about how their actions apply to different chronic conditions. The system also generates quality measures based on outcomes, processes, satisfaction, and utilization, with each care team receiving its quality results. “[Providers] can go to the website and retrieve [the results] and see how they are doing compared to every other team.” An arrangement with the unions representing workers allowed a test of linking pay to quality results. “It is ‘walking the talk’ and showing that this does in fact matter in terms of what we evaluate and value,” said Raphael.
The technology has also enabled information exchanges with hospitals and physicians. For example, pilot programs with several large physician groups are evaluating the exchange in real time of information about patients shared in common. Raphael said, “That will really be a breakthrough for us in terms of changing how we think about what we do.”
The Evolving Roles of Nurses
The roles of nurses at the VNSNY have evolved from being task-oriented and transactional to being outcomes-oriented and relational. Nurses used to have short-term relationships with patients; when they changed a wound dressing, they did it alone; and payments were tied to fee-for-service systems and volume. Now, the system has shifted to an emphasis on outcomes over extended periods, such as the ability to regain function, prevent complications and decline, and maintain a good
quality of life. Nurses are the coordinators of interdisciplinary teams that can include physical, occupational, and speech therapists; social workers; family and other informal caregivers; physicians; and pharmacists. Raphael recalled, “One of the nurses said to me, ‘It used to be about me. Now, it is about the patient.’”
Raphael identified six skills that community health nurses will need in the future. Nurses need the ability to
Assess risk levels, functional impairments, and the medical and support needs of individuals;
Partner with the patient and the patient’s family to develop a reasonable and achievable plan of care;
Manage a cross-disciplinary team, including informal caregivers;
Coordinate care with other providers across settings;
Aggregate, synthesize, interpret, and act on clinical data; and
Communicate effectively with patients and caregiving teams.
The need for these skills has many implications for nursing education, in which VNSNY plays an active role. A nurse internship program offers new bachelor’s degree nursing graduates hands-on experience and mentoring by seasoned staff to prepare them for home-based nursing. Thirty members of the nursing staff are adjunct faculty at nursing schools. About 500 nursing students come through VNSNY on clinical rotations each year, but much of the education and training for VNSNY nurses still occurs on the job. “We really have to do a lot of our own education and training to compensate for the fact that most of the nurses don’t come with the experience, the competencies, or the comfort and confidence with technology that we think they need,” Raphael concluded.
THE FUTURE OF NURSES IN COMMUNITY CARE
Dr. Eileen Sullivan-Marx, the associate dean for practice and community affairs at the University of Pennsylvania School of Nursing, recently chaired a commission in Pennsylvania on the future of senior care services and resources in the state. As the only nurse on the commission, she applied a lesson well known among nurses: “Hearing from the public is an important piece to get you to that next step.”
Within the context of senior care services, the commission examined the current state of nursing, data about its future, and where the profession is headed. Yet understanding nursing also requires understanding
the passion of the individuals in the profession. “This is particularly important with students,” Sullivan-Marx said. “Students often resonate with different images of nursing than do members of older generations.”
Attracting people to community nursing requires social marketing, including discussion of price, place, promotion, and positioning. Working in the community has to be an attractive career track for nurses, and it has to have social and financial returns comparable to the investments made in the profession and to other career paths that nurses can pursue. Communities need to be accessible, and target audiences need to be made aware of what community nurses do.
Nurses are among the most trusted professionals in the United States, Sullivan-Marx said. Yet community nursing usually remains invisible in the broader society. Community nurses need to position themselves to have maximum benefits and minimal costs if the profession is to remain viable.
The Health Resources and Services Administration (HRSA) has studied the projected supply, demand, and shortages of nurses up to 2020 (HRSA, 2004b) and has found that the projected demand for registered nurses will rise most quickly for nurses working in the community; see Table 3-1 and Table 3-2. “We are still thinking much more about workforce shortages in hospitals, and, yes, that is where it is acute. But look where the real projected demand is … in home health care, with community care beyond that,” said Sullivan-Marx.
TABLE 3-1 National Measures of Projected Nurse Staffing Intensity
TABLE 3-2 Projected Demand for FTE RNs
Sullivan-Marx offered seven recommendations for the committee when considering the future of home, community, and public health nursing:
Establish professional nursing roles in places where people live and work. Students need to learn and seek jobs in these settings. For example, Sullivan-Marx tries to get her students into health fairs and other activities in the community. However, there are not enough opportunities for students to gain experience in the community.
Maximize benefits and minimize costs. This requires reframing care not by place but by skills and services. Skills should not be limited to a particular setting. “We are still too much bound by settings and how we think about payment structures and where nurses go,” said Sullivan-Marx
Enable nurses to control practice. Payment for nursing services needs to be visible, transparent, fair, and based on outcome incentives. Sullivan-Marx said, “Payment is the recognition of our authority to practice by society.”
Foster and recognize independent decision making by basic and advanced practice nurses. Although progress has been made in this area, many problems remain. For example, Sullivan-Marx noted that changes in Pennsylvania have enabled nurses to order
durable medical equipment, but by federal statute they cannot do so if the equipment is paid for by Medicare.
Establish quality in community care as a core competency for all nurses. Patient safety considerations extend far beyond the boundaries of hospitals, and the core competencies taught in nursing schools should reflect that fact.
Embrace family- and patient-centered care with a team of providers with nurses as leaders in care.
Finally, lead the return and renewal of public health nursing.
RESPONSES TO QUESTIONS
In response to a question about recruiting and retaining nurses, Raphael noted that the VNSNY “had a very difficult time in recruitment” until about a year and a half ago. Before that, VNSNY paid sign-on bonuses, but nurses tended to come for one year and then leave to get a sign-on bonus elsewhere. In response, the organization decided to focus special attention on retention. Raphael noted that all new employees have a mentor who keeps in touch regularly. Efforts are made not to overwhelm new employees and to address any issues early. Because the staff works in the field, VNSNY tries to establish social networks to increase interactions. As a result of these efforts, Raphael said that VNSNY now has just a 2 percent vacancy rate among nurses in its certified home health agency.
VNSNY also has had difficulties recruiting staff from diverse communities. About 20 percent of its patients are Hispanic, but less than 2 percent of nurses in the United States are Hispanic, “so there is a mismatch in the pool,” said Raphael. Some nurses are going to a Berlitz course to learn Spanish, while others travel with translators. Raphael also said that at one point, VNSNY had many Korean patients but virtually no Korean nurses. Finally, by recruiting one Korean nurse, they were able to make contact with others, and now they have 29 Korean nurses. “Recruitment efforts have been completely through the community.”
Sullivan-Marx noted that retention also has improved in a comprehensive program of full-time interdisciplinary care with which she is involved—from more than 30 percent turnover several years ago to about 5 percent. “The reason our folks stay … is because they feel they are making a difference. They also have benefits that we are able to offer through the university,” including opportunities for continuing education,
said Sullivan-Marx. One factor behind retention is that staff feel they are contributing to the communities where they were raised. “Many people say, ‘This woman was my teacher. I feel like I am giving her the best care that I could possibly give.’”
Sullivan-Marx added that recruiting new, young nurses directly from school is more difficult because they may not have the ability to “jump in and do the independent, critical thinking that is required in community care.” They may struggle with their roles and what is expected of them.
Raphael said that her organization has attracted people from other fields, such as financial services or the media, who are interested in becoming nurses, but “it is not easy to make that leap.” The largest source of nurses for VNSNY is the acute care setting. The organization has a 3-week orientation program for nurses from acute care or nursing homes to introduce them to community care, followed by continuing education. Raphael said, “The nurses often find it very difficult, because you don’t have someone down the hall you can go to ask for advice. You are often completely autonomous, and you have to make judgment calls.” Raphael described a family in which a woman with severe cancer insisted that 24 hours before she died she should be moved to a hospital so that her spirit would not remain in the family home. The new nurse was “very rattled,” said Raphael. “She wanted to be sure she made this family feel comfortable. I don’t think she felt 100 percent sure she was going to know 24 hours before that that was the time, though an experienced hospice nurse would have known.”
There needs to be a culture shift so that nurses seek help when it is needed; community and public health nurses need to feel that they can reach out and ask for help. “You have to figure out a way to give ongoing support and help as these unexpected issues emerge,” Raphael said. Sullivan-Marx emphasized the importance of mentorship programs to support and educate nurses new to community care.
Sullivan-Marx noted during her talk that nursing cannot remain a largely female profession. “We are not going to be able to meet the demand.” Raphael observed that VNSNY has had success recruiting males from fire departments and the military. “People have worked for 20 to 25 years. They are in their forties, and now they want a second career,” noted Raphael. As a result of targeted recruitment, her organization has a higher percentage of men in the nursing workforce than is the case elsewhere.
In response to a question about technologies that could help community nursing, Raphael mentioned remote patient monitoring and the
evaluation of so-called smart homes that use sensors placed throughout the home to monitor patients’ mobility, medication use, and potential problems. This technology creates a different role for nurses, who have to interpret information remotely and determine when someone needs a visit from a caregiver. “Some of the nurses are welcoming that role, and this is a technology we are looking at seriously.” She also said that VNSNY nurses often take photographs of wounds and show the photographs to wound care specialists and physicians to determine if a therapy needs to be changed. “One of the most important things we can do is link with the primary care physician and be able to exchange clinical information on a continuous basis,” she noted.
Sullivan-Marx also cited the potential for technologies to maintain communication between patients and nurses. For example, family caregivers may need to access information from nurses 24 hours a day. Technologies that can provide information quickly and easily would be welcomed by these families.