- Email: [email protected]
The Role of Nurse Leaders in Primary Care
The Role of Nurse Leaders in Primary Care By Cheryl L. Hoying, PhD, RN, NEA-BC, FACHE, FAAN Senior Vice President, Patient Services Cincinnati Children’s Hospital Medical Center Cincinnati, OH
A
s 32 million uninsured Americans prepare to begin seeking primary care in 2014 as a result of the Patient Protection and Affordable Care Act (ACA), the continuous nurse and physician workforce fluctuations have elevated to a heightened level of concern. Health care leaders nationwide have been wondering who will take care of the mass arrival of new patients and how our health care model needs to change in order provide such access. A few years ago, the American Hospital Association (AHA) Workforce Center decided to assist hospitals in addressing these questions by assembling a group of health care leaders to discuss two important issues: 1. Defining the future primary care workforce needs for patients/families 2. Providing a framework around the role of hospitals in providing primary care services The deliverable was the white paper “Workforce Roles in a Redesigned Primary Care Model,” published in January 2013 by AHA, that developed a set of guiding principles and made specific recommendations on how hospitals can lead the transition to a new model of primary care delivery. As president of the American Organization of Nurse Executives (AONE), I participated on the roundtable with three other nurse leaders and five physician leaders. Through a number of phone calls and a two-day meeting Sept. 24-25, 2011, we collaborated and discussed new frameworks for redefining and redesigning primary care services. It was a rewarding personal experience that resulted in great dialogue and camaraderie with professionals putting patients first and driving for solutions. The AHA paper offers recommendations specifically regarding primary care that may seem peripheral to some nurse leaders whose primary role is in the hospital setting. However, chief nursing officers have a unique opportunity to get more involved as the sector grows. As the individuals responsible for patients across the continuum, nurse executives must advocate for standards in all patient care areas—including outpatient, behavioral www.nurseleader.com
health, palliative care, and other areas where nursing is practiced. This requires a cultural shift from the “inpatient vs outpatient” model to the all-encompassing “continuum of care.” Since I started my role as senior vice president of patient services at Cincinnati Children’s Hospital Medical Center in 2005, the care continuum has been at the forefront of my vision. Over the years, my role has expanded beyond oversight of nursing in the inpatient units and allied health professionals to the outpatient setting, urgent care sites, satellite locations, and home care. I also integrated our separate nursing and allied health shared-governance structures to ensure our clinical staff effectively work as a team and collaborate to solve complex issues. Mary Tonges, senior vice president and chief nursing officer at the University of North Carolina Hospitals, who was also at the meeting, said that, as a reminder, nursing practice (regardless of reporting structure) and standards of nursing care fall under the role of the chief nursing officer, as indicated by the Joint Commission. But we, along with the rest of nursing practice, still have a few major shifts to undergo to be successful in primary care. With the development of the care coordinator role (called health coaches, community liaisons, and a variety of other names by organizations nationwide), registered nurses (RNs) will be definitively responsible for triaging patients, educating them, and managing their overall care, while advance practice registered nurses (APRNs) will diagnose and provide plans of care. (Refer to the “Accountability-Based Primary Care Workforce Model” in the paper to see how the health care team is assembled.) As leaders, we must become clear about defining and standardizing the role of each member of the health care team. We must also develop stronger connections, both within organizations and within the community. More than ever, interprofessional collaboration is vital to the success of our patients. I learned this quickly in my role as interim dean at the University of Cincinnati College of Nursing, where nursing students interacted minimally
Nurse Leader
21
with the medical, pharmacy, or allied health students until after they left college and began their health care careers. It inspired me to initiate team-based simulation training and clinicals so that students could learn the skills involved in interprofessional teamwork. Teamwork is important externally as well. Nurse leaders need to get better at forging partnerships with community-based organizations. Often there are external sources that can augment health care services. United Way affiliates, local churches and synagogues, associations, and schools are all great resources embedded in the community where patients reside. It’s important to develop those relationships now to offset the extra work so nurses can focus on their roles: caring for patients’ health needs. Another important aspect of care coordination is technology. With a pending shortage of physicians and nurses, we must be open to the opportunities that technology will allow, such as better population management. Weight loss apps, GPS-wired asthma inhalers, and data aggregators all help us learn details about patients that will prove invaluable as we shift from an episode-centric care model to a prevention and wellness care model. I urge you to read the new AHA white paper (http://www.aha.org/content/13/13-0110-wfprimary-care.pdf) and speak to your team about your institution’s role in primary care. We have included an Executive Summary of this white paper on the next few pages. A great first step is to look at the tools offered by AHA and AONE online. The AONE Workplace Environment Assessment Survey, found at http://www.aone.org/resources/workforce_env_assess. shtml, will help you examine your current workforce and future trends. The Association for Community Health Initiatives (ACHI) has an important resource called the Community Health Assessment Toolkit, found at www.assesstoolkit.org, that helps plan, lead, and use community health assessments to better understand and improve the health of communities. Finally, visit AHA’s workforce website at www.healthcareworkforce.org for any additional information. There is a long road ahead of us, but I am confident that if we continue working together as leaders, staff, patients, and families, primary care in the United States will be more efficient and effective than ever.
“Future Patient Care Delivery,” AONE Guiding Principles/Toolkits, http://www.aone.org/resources/PDFs/AONE_GP_Future_Patient_Care_ Delivery_2010.pdf “Responding to the Medicaid Crisis: Leveraging the Care Continuum to Improve Beneficiary Health Status and Health System Economics,” the Advisory Board Company, http://www.advisory.com/Research/ Health-Care-Advisory-Board/Onsite-presentations/Responding-to-theMedicaid-Crisis “The Role of the Nurse in Future Patient Care Delivery,” AONE Guiding Principles/Toolkits, http://www.aone.org/resources/PDFs/AONE_GP_for_ Role_of_Nurse_Future.pdf “Workforce Roles in a Redesigned Primary Care Model,” American Hospital Association, http://www.aha.org/content/13/13-0110-wf-primary-care.pdf “Workplace Environment Assessment Survey,” AONE, http://www.aone.org/ resources/workforce_env_assess.shtml
Resources “Community Health Assessment Toolkit,” Association for Community Health Initiatives, www.assesstoolkit.org “For the Nurse Executive to Enhance Clinical Outcomes by Leveraging Technology,” AONE Guiding Principles/Toolkits, http://www.aone.org/ resources/PDFs/AONE_GP_Leveraging_Technology.pdf
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Workforce Roles in a Redesigned Primary Care Model Executive Summary
In September 2011, the American Hospital Association (AHA) convened a roundtable of clinical and health systems experts to examine the future primary care workforce needs of patients, as well as the role hospitals and health care systems can play in effectively delivering primary care. The AHA chose to focus on primary care access in light of the Patient Protection and Affordable Care Act (ACA), which will provide access to insurance coverage to an estimated additional 32 million Americans, beginning in 2014. The roundtable members included nine physician and nurse leaders who were asked to develop a set of recommendations that hospitals and health care systems could use as they plan workforce strategies to meet the upcoming demands for primary care services. The findings presented in this white paper reflect this group’s discussion and recommendations on two fronts: first, how to define workforce roles for a new primary care environment; and second, developing a new, more effective model of primary care delivery that encompasses the birth to end-of-life continuum. These recommendations take into account a variety of facility resources, including those related to finances and staffing, that must be considered if the redesign is to be successful.
Recommendation Summary Workforce 1. All health care professionals should be educated within the context of inter-disciplinary clinical learning teams. Clinical education system redesign should include curricula that support inter-disciplinary, team-based learning. These changes are necessary to prepare a workforce able to function well in integrated, multi-disciplinary care teams. Perhaps an even greater challenge is the re-education of the current workforce to work in a team-based model of care. Primary Care Delivery Model 1. Primary health care should be centered around the patient and family in a user-driven design, in all aspects of practice. This recommendation is at the core of primary care redesign and, without it, all other recommendations for redesign may not be sustainable.
2. Hospitals should evolve from traditional “hospitals” to “health systems,” partnering with community organizations and patients in order to advance the community’s wellness and health needs. The roundtable recognized that efforts have been made in the past to configure a new system. However, this recommendation is different in that it emphasizes that without effective linkage with the community, this evolution will not be successful.
www.nurseleader.com
3. Hospitals, or health systems, can serve as
catalysts for linking and integrating the various components of health and wellness together for patients in a way that provides a sustainable infrastructure of health care for patients and the community. The roundtable underscored the fundamental and pivotal role of health systems in redesigning primary care due to their status in— and responsibility for—the communities they serve.
4. In order to mitigate rising health care costs, a
fundamental shift in reimbursement will need to occur. This means patients and organizations alike will need to transition from the episodic, fee-for-service model of reimbursement to a new model that will reimburse for and encourage wellness and care across the health service continuum. By preventing and better managing the chronic conditions that afflict our population—or identifying them earlier in their course—the patient care experience can improve, providers will be better able to deliver quality care and, overall, costs can be reduced. The primary care clinical workforce is in an excellent position to influence this change in significant ways. The roundtable noted that this shift will require significant legislative and reimbursement reform, involving broad participation by the health care community.
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Guiding Principles Summary Based on these recommendations, the roundtable developed this set of guiding principles to help stakeholders address primary care workforce issues and the necessary redesign of primary care delivery systems:
1. In partnership with the patient, the primary health care team is guided by what is best, needed and helpful to the patient and family.
2. Workforce: The workforce must change how it
functions on multiple levels. Care must be provided by inter-professional teams where work is role-based, not task-based, and the team must be empowered to create effective approaches for delivering care.
3. Primary Care Delivery Model: Hospitals can serve
as conveners and enablers in primary care delivery. Primary care should be integrated into current and future care systems and hospitals should form effective partnerships with the community and patients in a way that provides the infrastructure primary care teams need to deliver quality care.
Accountability-Based Primary Care Workforce Model Summary In putting forth a new primary care workforce model, the goal was not to set rigid systems and constraints, but rather to set forth a framework that would encourage further dialogue, and from that, let the model further evolve to meet the needs of individual communities. The design developed by the roundtable, the Accountability-Based Primary Care Workforce Model (see page 12), is a hub-and-spoke model, with the patient, family and healthy community at the center. Radiating out from this are different health care roles
and professionals who each deliver care within their scope of practice and work collaboratively in a teambased model. In this model, the interface between and among team members is well-defined as well as their individual responsibilities. Within this framework, team communication becomes more effective and providers can be appropriately matched with both service demands and patient population needs. One example of this model in current practice is the “health home.”
AHA Primary Care Workforce Roundtable List of Members John Combes, MD Senior Vice President, AHA President & Chief Operating Officer, Center for Healthcare Governance Chicago, IL Joseph P. Frolkis, MD, PhD, FACP, FAHA Director of Primary Care Associate Chief of General Medicine for Primary Care Brigham and Women’s Hospital Boston, MA Cheryl L. Hoying, PhD, RN, NEA-BC, FACHE, FAAN Senior Vice President, Patient Services Cincinnati Children’s Hospital Medical Center Cincinnati, OH R. Cyrus Huffman, MD Senior Vice President/Chief Medical Officer Erlanger Health System Chattanooga, TN
Peter McGough, MD Chief Medical Officer, UW Medicine Neighborhood Clinics Associate Clinical Professor, Dept. of Family Medicine Seattle, WA Judith A. Melin, MA, MD Medical Director and Chief Medical Services Officer Lahey Clinic Burlington, MA Tim Porter O’Grady, DM, EdD, ScD(h), FAAN Senior Partner, Tim Porter-O’Grady Associates, Inc., Atlanta, GA Associate Professor, Leadership Scholar, Arizona State University, Phoenix, AZ Visiting Professor, University of Maryland, Baltimore, MD
Chicago Office:
155 N. Wacker Drive Suite 400 Chicago, IL 60606-1725
Pamela A. Thompson, MS, RN, CENP, FAAN Senior Vice President for Nursing, AHA Chief Executive Officer, AONE Washington, DC Mary Tonges, RN, PhD, FAAN Senior Vice President and Chief Nursing Officer The University of North Carolina Hospitals Chapel Hill, NC Staff Liaison: Veronika Riley Director of Special Projects AONE/AHA Washington, DC
Washington, D.C. Office: Liberty Place 325 Seventh Street, NW Washington, DC 20004-2802
©2013 American Hospital Association
www.aha.org
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June 2013
A
s 32 million uninsured Americans prepare to begin seeking primary care in 2014 as a result of the Patient Protection and Affordable Care Act (ACA), the continuous nurse and physician workforce fluctuations have elevated to a heightened level of concern. Health care leaders nationwide have been wondering who will take care of the mass arrival of new patients and how our health care model needs to change in order provide such access. A few years ago, the American Hospital Association (AHA) Workforce Center decided to assist hospitals in addressing these questions by assembling a group of health care leaders to discuss two important issues: 1. Defining the future primary care workforce needs for patients/families 2. Providing a framework around the role of hospitals in providing primary care services The deliverable was the white paper “Workforce Roles in a Redesigned Primary Care Model,” published in January 2013 by AHA, that developed a set of guiding principles and made specific recommendations on how hospitals can lead the transition to a new model of primary care delivery. As president of the American Organization of Nurse Executives (AONE), I participated on the roundtable with three other nurse leaders and five physician leaders. Through a number of phone calls and a two-day meeting Sept. 24-25, 2011, we collaborated and discussed new frameworks for redefining and redesigning primary care services. It was a rewarding personal experience that resulted in great dialogue and camaraderie with professionals putting patients first and driving for solutions. The AHA paper offers recommendations specifically regarding primary care that may seem peripheral to some nurse leaders whose primary role is in the hospital setting. However, chief nursing officers have a unique opportunity to get more involved as the sector grows. As the individuals responsible for patients across the continuum, nurse executives must advocate for standards in all patient care areas—including outpatient, behavioral www.nurseleader.com
health, palliative care, and other areas where nursing is practiced. This requires a cultural shift from the “inpatient vs outpatient” model to the all-encompassing “continuum of care.” Since I started my role as senior vice president of patient services at Cincinnati Children’s Hospital Medical Center in 2005, the care continuum has been at the forefront of my vision. Over the years, my role has expanded beyond oversight of nursing in the inpatient units and allied health professionals to the outpatient setting, urgent care sites, satellite locations, and home care. I also integrated our separate nursing and allied health shared-governance structures to ensure our clinical staff effectively work as a team and collaborate to solve complex issues. Mary Tonges, senior vice president and chief nursing officer at the University of North Carolina Hospitals, who was also at the meeting, said that, as a reminder, nursing practice (regardless of reporting structure) and standards of nursing care fall under the role of the chief nursing officer, as indicated by the Joint Commission. But we, along with the rest of nursing practice, still have a few major shifts to undergo to be successful in primary care. With the development of the care coordinator role (called health coaches, community liaisons, and a variety of other names by organizations nationwide), registered nurses (RNs) will be definitively responsible for triaging patients, educating them, and managing their overall care, while advance practice registered nurses (APRNs) will diagnose and provide plans of care. (Refer to the “Accountability-Based Primary Care Workforce Model” in the paper to see how the health care team is assembled.) As leaders, we must become clear about defining and standardizing the role of each member of the health care team. We must also develop stronger connections, both within organizations and within the community. More than ever, interprofessional collaboration is vital to the success of our patients. I learned this quickly in my role as interim dean at the University of Cincinnati College of Nursing, where nursing students interacted minimally
Nurse Leader
21
with the medical, pharmacy, or allied health students until after they left college and began their health care careers. It inspired me to initiate team-based simulation training and clinicals so that students could learn the skills involved in interprofessional teamwork. Teamwork is important externally as well. Nurse leaders need to get better at forging partnerships with community-based organizations. Often there are external sources that can augment health care services. United Way affiliates, local churches and synagogues, associations, and schools are all great resources embedded in the community where patients reside. It’s important to develop those relationships now to offset the extra work so nurses can focus on their roles: caring for patients’ health needs. Another important aspect of care coordination is technology. With a pending shortage of physicians and nurses, we must be open to the opportunities that technology will allow, such as better population management. Weight loss apps, GPS-wired asthma inhalers, and data aggregators all help us learn details about patients that will prove invaluable as we shift from an episode-centric care model to a prevention and wellness care model. I urge you to read the new AHA white paper (http://www.aha.org/content/13/13-0110-wfprimary-care.pdf) and speak to your team about your institution’s role in primary care. We have included an Executive Summary of this white paper on the next few pages. A great first step is to look at the tools offered by AHA and AONE online. The AONE Workplace Environment Assessment Survey, found at http://www.aone.org/resources/workforce_env_assess. shtml, will help you examine your current workforce and future trends. The Association for Community Health Initiatives (ACHI) has an important resource called the Community Health Assessment Toolkit, found at www.assesstoolkit.org, that helps plan, lead, and use community health assessments to better understand and improve the health of communities. Finally, visit AHA’s workforce website at www.healthcareworkforce.org for any additional information. There is a long road ahead of us, but I am confident that if we continue working together as leaders, staff, patients, and families, primary care in the United States will be more efficient and effective than ever.
“Future Patient Care Delivery,” AONE Guiding Principles/Toolkits, http://www.aone.org/resources/PDFs/AONE_GP_Future_Patient_Care_ Delivery_2010.pdf “Responding to the Medicaid Crisis: Leveraging the Care Continuum to Improve Beneficiary Health Status and Health System Economics,” the Advisory Board Company, http://www.advisory.com/Research/ Health-Care-Advisory-Board/Onsite-presentations/Responding-to-theMedicaid-Crisis “The Role of the Nurse in Future Patient Care Delivery,” AONE Guiding Principles/Toolkits, http://www.aone.org/resources/PDFs/AONE_GP_for_ Role_of_Nurse_Future.pdf “Workforce Roles in a Redesigned Primary Care Model,” American Hospital Association, http://www.aha.org/content/13/13-0110-wf-primary-care.pdf “Workplace Environment Assessment Survey,” AONE, http://www.aone.org/ resources/workforce_env_assess.shtml
Resources “Community Health Assessment Toolkit,” Association for Community Health Initiatives, www.assesstoolkit.org “For the Nurse Executive to Enhance Clinical Outcomes by Leveraging Technology,” AONE Guiding Principles/Toolkits, http://www.aone.org/ resources/PDFs/AONE_GP_Leveraging_Technology.pdf
22
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June 2013
Workforce Roles in a Redesigned Primary Care Model Executive Summary
In September 2011, the American Hospital Association (AHA) convened a roundtable of clinical and health systems experts to examine the future primary care workforce needs of patients, as well as the role hospitals and health care systems can play in effectively delivering primary care. The AHA chose to focus on primary care access in light of the Patient Protection and Affordable Care Act (ACA), which will provide access to insurance coverage to an estimated additional 32 million Americans, beginning in 2014. The roundtable members included nine physician and nurse leaders who were asked to develop a set of recommendations that hospitals and health care systems could use as they plan workforce strategies to meet the upcoming demands for primary care services. The findings presented in this white paper reflect this group’s discussion and recommendations on two fronts: first, how to define workforce roles for a new primary care environment; and second, developing a new, more effective model of primary care delivery that encompasses the birth to end-of-life continuum. These recommendations take into account a variety of facility resources, including those related to finances and staffing, that must be considered if the redesign is to be successful.
Recommendation Summary Workforce 1. All health care professionals should be educated within the context of inter-disciplinary clinical learning teams. Clinical education system redesign should include curricula that support inter-disciplinary, team-based learning. These changes are necessary to prepare a workforce able to function well in integrated, multi-disciplinary care teams. Perhaps an even greater challenge is the re-education of the current workforce to work in a team-based model of care. Primary Care Delivery Model 1. Primary health care should be centered around the patient and family in a user-driven design, in all aspects of practice. This recommendation is at the core of primary care redesign and, without it, all other recommendations for redesign may not be sustainable.
2. Hospitals should evolve from traditional “hospitals” to “health systems,” partnering with community organizations and patients in order to advance the community’s wellness and health needs. The roundtable recognized that efforts have been made in the past to configure a new system. However, this recommendation is different in that it emphasizes that without effective linkage with the community, this evolution will not be successful.
www.nurseleader.com
3. Hospitals, or health systems, can serve as
catalysts for linking and integrating the various components of health and wellness together for patients in a way that provides a sustainable infrastructure of health care for patients and the community. The roundtable underscored the fundamental and pivotal role of health systems in redesigning primary care due to their status in— and responsibility for—the communities they serve.
4. In order to mitigate rising health care costs, a
fundamental shift in reimbursement will need to occur. This means patients and organizations alike will need to transition from the episodic, fee-for-service model of reimbursement to a new model that will reimburse for and encourage wellness and care across the health service continuum. By preventing and better managing the chronic conditions that afflict our population—or identifying them earlier in their course—the patient care experience can improve, providers will be better able to deliver quality care and, overall, costs can be reduced. The primary care clinical workforce is in an excellent position to influence this change in significant ways. The roundtable noted that this shift will require significant legislative and reimbursement reform, involving broad participation by the health care community.
Nurse Leader
23
Guiding Principles Summary Based on these recommendations, the roundtable developed this set of guiding principles to help stakeholders address primary care workforce issues and the necessary redesign of primary care delivery systems:
1. In partnership with the patient, the primary health care team is guided by what is best, needed and helpful to the patient and family.
2. Workforce: The workforce must change how it
functions on multiple levels. Care must be provided by inter-professional teams where work is role-based, not task-based, and the team must be empowered to create effective approaches for delivering care.
3. Primary Care Delivery Model: Hospitals can serve
as conveners and enablers in primary care delivery. Primary care should be integrated into current and future care systems and hospitals should form effective partnerships with the community and patients in a way that provides the infrastructure primary care teams need to deliver quality care.
Accountability-Based Primary Care Workforce Model Summary In putting forth a new primary care workforce model, the goal was not to set rigid systems and constraints, but rather to set forth a framework that would encourage further dialogue, and from that, let the model further evolve to meet the needs of individual communities. The design developed by the roundtable, the Accountability-Based Primary Care Workforce Model (see page 12), is a hub-and-spoke model, with the patient, family and healthy community at the center. Radiating out from this are different health care roles
and professionals who each deliver care within their scope of practice and work collaboratively in a teambased model. In this model, the interface between and among team members is well-defined as well as their individual responsibilities. Within this framework, team communication becomes more effective and providers can be appropriately matched with both service demands and patient population needs. One example of this model in current practice is the “health home.”
AHA Primary Care Workforce Roundtable List of Members John Combes, MD Senior Vice President, AHA President & Chief Operating Officer, Center for Healthcare Governance Chicago, IL Joseph P. Frolkis, MD, PhD, FACP, FAHA Director of Primary Care Associate Chief of General Medicine for Primary Care Brigham and Women’s Hospital Boston, MA Cheryl L. Hoying, PhD, RN, NEA-BC, FACHE, FAAN Senior Vice President, Patient Services Cincinnati Children’s Hospital Medical Center Cincinnati, OH R. Cyrus Huffman, MD Senior Vice President/Chief Medical Officer Erlanger Health System Chattanooga, TN
Peter McGough, MD Chief Medical Officer, UW Medicine Neighborhood Clinics Associate Clinical Professor, Dept. of Family Medicine Seattle, WA Judith A. Melin, MA, MD Medical Director and Chief Medical Services Officer Lahey Clinic Burlington, MA Tim Porter O’Grady, DM, EdD, ScD(h), FAAN Senior Partner, Tim Porter-O’Grady Associates, Inc., Atlanta, GA Associate Professor, Leadership Scholar, Arizona State University, Phoenix, AZ Visiting Professor, University of Maryland, Baltimore, MD
Chicago Office:
155 N. Wacker Drive Suite 400 Chicago, IL 60606-1725
Pamela A. Thompson, MS, RN, CENP, FAAN Senior Vice President for Nursing, AHA Chief Executive Officer, AONE Washington, DC Mary Tonges, RN, PhD, FAAN Senior Vice President and Chief Nursing Officer The University of North Carolina Hospitals Chapel Hill, NC Staff Liaison: Veronika Riley Director of Special Projects AONE/AHA Washington, DC
Washington, D.C. Office: Liberty Place 325 Seventh Street, NW Washington, DC 20004-2802
©2013 American Hospital Association
www.aha.org
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