Chronic and Long-Term Services and Supports
NURSES’ ROLES IN MEETING LONG-TERM HEALTH CARE NEEDS
Within the next two decades, at least 20 percent of Americans will be 65 and older. Nurses must play a leadership role in caring for this population, said Dr. Claudia Beverly, professor in the Colleges of Nursing, Medicine, and Public Health at the University of Arkansas for Medical Sciences. Members of this population will be in their own homes and in nursing homes, hospitals, and assisted living facilities. Nurses must take a leadership role in caring for this population, Beverly emphasized.
Today the nursing workforce is inadequately prepared for the challenges of an aging population, Beverly said. Reimbursements outside acute care settings are not competitive; there is poor coordination among care settings; and there has been a lack of leadership and gerontological content throughout the nursing curriculum, from the associate to the bachelor’s to the post-baccalaureate degree levels (Berman et al., 2005; IOM, 2008; Kovner et al., 2002).
Nurses also have been reluctant to take positions as decision makers within the health care system. As a result, chronic care tends to be relatively unmanaged, and there is a lack of emphasis on prevention and health promotion. In addition, Beverly said, practice constraints continue to be a problem throughout the health care system (Hooker et al., 2005; IOM, 2008).
Implementation and use of existing and new technology have been slow. Beverly highlighted a number of challenges related to the availability and use of technology: many nursing homes have either no or only one computer, which is usually reserved for billing purposes; there is
little funding for either equipment or interventions using technology; very little money is available to place electronics into nursing homes to enable early interventions; and electronic health records have not been adopted widely in geriatric care practices (Committees on Energy and Commerce, Ways and Means, and Science and Technology, 2009; Hillestead et al., 2005).
Despite the abundance of challenges, Beverly cited accomplishments in long-term care and geriatric nursing led and supported by the John A. Hartford Foundation, the Geriatric Nurse Leadership Academy, the Donald W. Reynolds Foundation, stateside education consortia in Oregon and Minnesota, and the Sigma Theta Tau International Center for Nursing Excellence in Long-Term Care. For example, Sigma Theta Tau’s Geriatric Nurse Leadership Academy just produced its first cohort of 16 nurses. The program “has had phenomenal results,” said Beverly, “and we will be moving into our second year this spring.”
Beverly offered three recommendations to the committee. First, a well-prepared long-term care workforce is essential for providing quality health care for older adults. There needs to be a strong pipeline, starting in middle schools and high schools, that leads to registered nurse programs. Also, the in-home health care curriculum is neither mandatory nor standardized in nursing education currently. “Nursing needs to play a role in making sure we have a strong curriculum that includes topics such as dementia and other topics.” In particular, Beverly said that geriatric curricula in all registered nurse programs need to be reviewed “because a lot of programs say, ‘we don’t have a stand-alone [unit] but we integrate it,’ but then when you look for where it is integrated, it’s not.” All registered nurses working in assisted living facilities, in nursing homes, or in home health care need to have adequate preparation in geriatric nursing. Closer relationships are also needed with geriatric nursing centers, which are supported through a federally funded program to provide education for health care professionals, noted Beverly.
Second, Beverly suggested that nurses must participate in and influence any major health care discussions about long-term care. Nurses “have not been aggressive in positioning ourselves to be part of that decision making,” she said. Evidence-based models of care need to be incorporated into the health care delivery system, with the most appropriate provider paired with the right need. The role of registered nurses should be clearly articulated in every aspect of long-term care, and reimbursement systems should be rebalanced to embrace the full use of registered nurses.
Third, Beverly suggested a greatly increased use of technology. It should be applied in homes, in nursing homes, and in assisted living facilities. It should be used to improve education in schools and the delivery of nursing care. Also, in the form of electronic health records, the use of technology can greatly improve the coordination of care.
EVERCARE MODELS OF NURSING
Chronic diseases account for 75 percent of the nation’s health care spending, and about two-thirds of the rise in health care spending is due to the increase in the prevalence of treatable chronic diseases, said Lynda Hedstrom, senior director of clinical services for Ovations. Yet vulnerable elders—people 65 and older who are at moderate or high risk for functional decline or death in the next 2 years—receive only about half of the recommended care (Wenger et al., 2003). “The idea that 100 people turn 60 every 13 minutes either keeps you up at night with anxiety or gives you some excitement about possibilities for the future,” said Hedstrom.
The Evercare model that was developed by Ovations is based on special needs plans (sometimes known as SNPs) created by the Medicare Modernization Act of 2003. The special needs plans constitute a category of Medicare advantage plans that are designed to attract and enroll Medicare beneficiaries who fall into certain special needs demographics, including people who are institutionalized, who are eligible for both Medicare and Medicaid, or who have severe or disabling conditions. Hedstrom said that the plans go beyond the minimum that Medicare offers to provide care that is unique or special to their populations, such as transportation benefits or preventive dentistry for community-based members of the plan.
The Evercare model focuses on developing personalized health care plans, preventive services, and support for caregivers. It is designed to improve the coordination of care, enhance the quality of care by treating recipients at home, control costs, and produce outcomes important to these populations. With leadership from nurses, nurse practitioners, and care managers, the program monitors health status, manages chronic diseases, facilitates communication, avoids inappropriate hospitalizations, helps beneficiaries move from high risk to lower risk on the care continuum, aligns advance care planning with patient goals, and offers palliative care services.
Hedstrom described several studies that have demonstrated the benefits of this approach to care. In nursing homes, it reduces hospitalization (Kane et al., 2004), improves the cost effectiveness of care (Kane et al., 2003), and enhances family satisfaction (Kane et al., 2002). “Our family satisfaction surveys are still above 97 percent for that model,” said Hedstrom.
In the community setting, the Assessing Care of Vulnerable Elders (ACOVE) project undertaken by RAND Health demonstrated improved geriatric care. The study developed quality indicators for medical conditions (e.g., chronic obstructive pulmonary disease, heart failure, diabetes, depression) and geriatric conditions (e.g., dementia, delirium, mobility disorders, incontinence) and found that Evercare providers did better than others in meeting these quality measures. The bottom line, said Hedstrom, is that the outcomes demonstrate “a significant improvement by our nursing interventions.”1
Hedstrom drew several conclusions from these study results; she noted that care provided by physicians is generally good for medical conditions. However, when physicians partner with nurses in the Evercare model to provide care, there is significant improvement in quality indicators for geriatric conditions. According to clinical measures, patients without Evercare nurse contact receive worse care.2 Hedstrom noted that nurses directly impact the quality and cost of health care.
These observations raise several intriguing questions, observed Hedstrom. Is the U.S. health care system ready to accept nurses as full partners in the provision of care, even to the extent of having independent and competitive practices? Would the health care system be willing to pay nurses directly? And what would have to change in terms of education, policy, and reimbursement practices for this to happen?
RESPONSES TO QUESTIONS
In response to a question about increasing the diversity of the nursing workforce to care for the aging population, Beverly noted that Hispanics and African Americans are underrepresented in the nursing profession.
However, many direct care workers are African Americans, often working near their own communities and demonstrating a love for caring for older adults. Not all of these individuals want to go into nursing, because they are very happy with what they are doing, “but there is a percentage—roughly expected to be around 30 percent—who would want to move into nursing, and I think it is up to us to try to move [them] on,” said Beverly. For example, at an aging center in West Memphis, Arkansas, an African-American geriatrician and education director who is a nurse have been recruiting in churches, schools, and wherever they can show potential students that “there is a place for me there.”
Another questioner asked about foreign-trained nurses in long-term care settings; Beverly observed that the content of their education is uncertain, although in the United States “we have not been consistently educating nurses at all levels to have expertise or at least a baseline in geriatric nursing and leadership.” Beverly noted that most registered nurses (RNs) who work in nursing homes operate in director-of-nursing positions. If all nursing homes and other long-term care facilities had computers and access to the Internet, online assessments and training for geriatric care could be delivered to all nurses in those settings, regardless of their educational background and roles within the long-term care facilities.
Hedstrom added that it is important to demonstrate the value of nurses and nursing interventions in long-term care settings. Such information could help make it possible to reimburse nurses, especially advanced practice nurses, for the contributions they make to better health care. For example, the studies done by Ovations of the Evercare model originated from a desire to know how to spend limited funds most effectively, but they also demonstrated in a public way the value of nursing.
In response to a question about the stigma that sometimes surrounds long-term care and the possibility of moving such care into the community, Hedstrom replied that “we ought to have neighborhood nurses, church nurses, synagogue nurses—I think that nurses bring a level of care to their communities wherever they are.” If nursing were more visible in these settings, people would be more willing to pay for the value nurses add. “The more we can define and make visible the special effects of nurses, the better,” said Hedstrom.
Beverly observed that the visibility of nurses is increasing—they are becoming “more articulate, more open, and a champion for students’ being in long-term care.” She also pointed out that nurses could offer a valuable service by visiting with people who are caring for elderly family