- Email: [email protected]
Transformation in times of change
President’s Message
Transformation in times of change
The Age of Transformation We are most certainly in an age of transformation. It is the word that comes to mind when I think of the opportunities ahead of us in nursing and the challenges that come with a political transition. The political landscape is still unfolding as I write this President’s message, but one thing is certaindwe will see a markedly changed policy environment. Health and health care in America will change, and I suggest that nursing could be a powerful voice to assure it is a positive transformation and not destructive. People are living longer, especially the elderly and chronically ill, often with complex health needs. The cost of health care is rising. Meanwhile, the health care system is beginning to change how it delivers and pays for care to meet the many demands it faces. The feefor-service system is evolving into one that is value based, paying providers to keep people healthy. The public health system is reimagined as the chief health strategist for communities, states, and the nation. It is my hope that preventing illness will continue to be the best way to control health care spending and the best way to prevent illness. I hope to see care that is integrated, comprehensive, population-based, and personcentered become standard practice. I believe this is what we expect public health and primary health care to be. Health systems are beginning to use multidisciplinary teams because they promote efficient and costeffective health and health care. I believe that more and more we will see the management of complex health needs occurring beyond the acute care setting. The production of health and the management of illness in populations should be a collaborative enterprise across health systems, public health, and academia. Academic institutions are implementing curricular changes that reflect a focus on collaboration, teams, integrated care, a population focus, and managing care to create health in addition to managing disease. Some of this transformation is underway, but much of it is still in the distance. For this President’s message, I wanted to share a few examples of how four organizations have created reports related to the business of creating healthy populations. The reports carry multiple messages for nursing, public health, education, health care, and the future workforce. The audiences and topics for these reports vary widely, but much of them recommend pursuing active transformation. But much of what was developed, particularly work developed to provide a
context for and inform the next President as they establish a new set of leaders, priorities, and policies. The outcome of that work will unfold over time.
Informing the Future Innovation on the part of leaders in education, research, and practice has long guided the development of new models for organizing and delivering care. We have emphasized advanced education for health professionals, the creation of opportunities for interdisciplinary practice across disciplines and specialties, and the development of partnerships across academic health sciences and health systems. I want to share work underway that includes forecasting the future of health and health care including the workforce; an effort to redesign primary care using registered nurses (RNs) practicing at the top of their education, license, and scope of practice; transforming public health to create healthy communities; and enhancing partnerships among academic nursing and academic health centers and other health-related organizations. The examination of research, evidence, context, and policy led to the creation of these four reports: the National Academy of Science’s “Viewpoint Series on Health and Health Care,” the Macy Foundation’s report on Registered Nurses in Primary Care, the Public Health Leadership Forum’s development of a briefing document for the next administration titled “Transforming Public Health and Health Care to Create Healthy Communities,” and the American Association of Colleges of Nursing’s report on “Advancing Healthcare Transformation.” These reports set the context for change and transformation in policy, practice, and education. In an earlier President’s message, I discussed the recommendations from the Macy Foundation’s report, and I will briefly review them again. The other three documents may be well known to some of you, and others may not be familiar. The American Academy of Nursing along with many other partners has been represented in all these efforts.
National Academy of Medicine: Vital Directions for Health and Health Care A series of 19 articles were written by teams of national experts under the auspices of the National Academy of
2
Nurs Outlook xxx (2016) 1e3
Medicine with the purpose of informing the next administration about opportunities to improve health and health care and reduce poor outcomes of the U.S. population. A synthesis of the articles was published in JAMA (National Academy of Medicine, 2016) with the full articles available on the National Academy of Science Web site (https://nam.edu/initiatives/vital-directionsfor-health-and-health-care/). The themes that emerged from these 19 articles included the following: Understanding that the determinants of health are the basis of health or illness and require a different type of approach and partnerships. In addition to health professionals including nurses, other partners required for this venture will include those from economics, business, housing, transportation, education, and many more. Advancing wellness and prevention is a necessary set of strategies that all populations need and are critical to assuring population health. Strong systems of care including access to health insurance and comprehensive care will require a redesign of the way care is provided, integrated, and paid for. The 21st century workforce will need to be prepared to work toward the protection and enhancement of health and health care and prepared for practice in both a person-centered and population-based health environment where it is understood that engagement of individuals and populations in care design and prevention is necessary. Continuous improvement in care and outcomes will occur through a system of metrics and measurement that enables us to realize progress on a range of health indicators, including the leading health indicators, county health rankings, and the vital signs core measure set that foster quality improvement and continuous learning.
RNs: Partners in Transforming Primary Care This work was led by the Macy Foundation in partnership with the American Academy of Nursing and prompted by an urgency to transform the design of primary health care so it becomes more integrated, multidisciplinary, population focused, and engaged in care over the life span of individuals and across care environments that serve populations. The primary recommendations that emerged from the final report included the following: Leaders of nursing schools, primary care practices, and health systems should actively facilitate culture change that elevates primary care in RN education and practice. Primary care practices should redesign their care models to use the skills and expertise of RNs in meeting the health care needs of patientsdand
payers and regulators should facilitate this redesign. Nursing schools’ leaders and faculty should elevate primary care content in the education of prelicensure and RN to Bachelor of Science in Nursing (BSN) nursing students. Leaders of primary care practices and health systems should facilitate lifelong education and professional development opportunities in primary care and support practicing RNs in pursuing careers in primary care. Academia and health care organizations should partner to support and prepare nursing faculty to educate prelicensure and RN to BSN students in primary care knowledge, skills, and perspective. Leaders and faculty in nursing education and continuing education programs should include interprofessional education and teamwork in primary care nursing curricula (Josiah Macy Foundation, 2016).
Transforming Public Health and Health Care to Create Healthy Communities Under the auspices of the Public Health Leadership Forum funded by the Robert Wood Johnson Foundation, a team of public health, academic, and policy leaders were convened to develop a report intended to inform the next Secretary of the U.S. Department of Health and Human Services (HHS) about priorities for transforming the nation’s health. The report proposed that the role of chief health strategist should be assumed by the HHS Secretary and lead a national initiative to assure that “America’s communities are places that provide every person with the opportunity to achieve optimal health and are served by a strong public health infrastructure” (DHHS, 2016). The committee found that a growing body of evidence indicated that: A healthy nation is achieved by more than what happens in public health agencies and the health care system but by what happens within and among diverse communities and is realized through partnerships across communities, sectors, and levels of government. A healthy nation is built through engaged communities with equitable access to opportunities and resources achieved across all communities and populations. A healthy nation assures equitable access to and engagement in quality physical and behavioral health services and that all, regardless of race, ethnicity, gender or gender identity, or sexual orientation are served by a robust public health system. A healthy nation is safe and secure from and able to respond to natural and human-made threats and disasters.
Nurs Outlook xxx (2016) 1e3
Given these findings, the committee recommended that state and local public health systems and HHS: Transform the health care and public health investments by the federal government into a health promoting system and adopt metrics that foster activities that support longer high-quality life and reduce health inequities. Assure communities have the data, evidence, analytic capacity and flexibility they need to build healthy and resilient communities including supporting cross-sector collaborations at the federal, state, and local levels. Assure every community is served by a wellresourced public health department that is accredited and able to provide foundational capabilities and respond to unanticipated emergencies.
Advancing Health Care Transformation This report of the American Association of Colleges of Nursing described recommendations for a new era for academic nursing. The report was commissioned to examine and enhance partnerships between academic nursing and academic health centers. It presented the possibility of transforming education and clinical settings that are focused on innovation, integration, and the utilization of evidence-based practice (American Association of Colleges of Nursing [AACN], 2015). Included among its recommendations were the following:
Enhance the clinical practice of academic nursing. Partner in preparing the nurses of the future. Partner in the implementation of accountable care. Invest in nursing research programs and better integrate research into clinical practice. Implement an advocacy agenda to support a new era for academic nursing.
3
take these messages to our policymakers and academic and clinical leaders to make the case that producing a healthy nation is essential to a productive and progressive society.
references
American Association of Colleges of Nursing (AACN). (2015). Advancing healthcare transformation: A new era for academic nursing. Retrieved from http://www.aacn.nche.edu/AACNManatt-Report.pdf The Department of Health and Human Services as the nation’s chief health strategist: Transforming public health and health care to create healthy communities (2016). Retrieved from http://www.resolv.org/site-healthleadershipforum/ files/2016/09/DHHS-as-the-Nations-Chief-Health-Strategistcolor.pdf Josiah Macy Jr. Foundation. (2016). Registered nurses: Partners in transforming primary care: Recommendations from the Macy Foundation Conference on preparing registered nurses for enhanced roles in primary care. Retrieved from http://macyfoundation. org/docs/macy_pubs/201609_Nursing_Conference_Exectuive_ Summary_Final.pdf National Academy of Medicine. (2016). Viewpoint series presenting highlights from the National Academy of Medicine’s vital directions for health and health care discussion paper series. Retrieved from http://jamanetwork.com/journals/jama/article-abstract/ 2544650
Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN President American Academy of Nursing Columbia University School of Nursing Columbia University Medical Center New York, NY Corresponding author: Bobbie Berkowitz, 630 West 168th Street, MC6, New York, NY 10032. E-mail address: [email protected] Available online xxx
These four reports are among many expressions of hope for a future health system that is transformational in the way we view and express health. But this future is not guaranteed and will require all of us to
0029-6554/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2016.12.007
Transformation in times of change
The Age of Transformation We are most certainly in an age of transformation. It is the word that comes to mind when I think of the opportunities ahead of us in nursing and the challenges that come with a political transition. The political landscape is still unfolding as I write this President’s message, but one thing is certaindwe will see a markedly changed policy environment. Health and health care in America will change, and I suggest that nursing could be a powerful voice to assure it is a positive transformation and not destructive. People are living longer, especially the elderly and chronically ill, often with complex health needs. The cost of health care is rising. Meanwhile, the health care system is beginning to change how it delivers and pays for care to meet the many demands it faces. The feefor-service system is evolving into one that is value based, paying providers to keep people healthy. The public health system is reimagined as the chief health strategist for communities, states, and the nation. It is my hope that preventing illness will continue to be the best way to control health care spending and the best way to prevent illness. I hope to see care that is integrated, comprehensive, population-based, and personcentered become standard practice. I believe this is what we expect public health and primary health care to be. Health systems are beginning to use multidisciplinary teams because they promote efficient and costeffective health and health care. I believe that more and more we will see the management of complex health needs occurring beyond the acute care setting. The production of health and the management of illness in populations should be a collaborative enterprise across health systems, public health, and academia. Academic institutions are implementing curricular changes that reflect a focus on collaboration, teams, integrated care, a population focus, and managing care to create health in addition to managing disease. Some of this transformation is underway, but much of it is still in the distance. For this President’s message, I wanted to share a few examples of how four organizations have created reports related to the business of creating healthy populations. The reports carry multiple messages for nursing, public health, education, health care, and the future workforce. The audiences and topics for these reports vary widely, but much of them recommend pursuing active transformation. But much of what was developed, particularly work developed to provide a
context for and inform the next President as they establish a new set of leaders, priorities, and policies. The outcome of that work will unfold over time.
Informing the Future Innovation on the part of leaders in education, research, and practice has long guided the development of new models for organizing and delivering care. We have emphasized advanced education for health professionals, the creation of opportunities for interdisciplinary practice across disciplines and specialties, and the development of partnerships across academic health sciences and health systems. I want to share work underway that includes forecasting the future of health and health care including the workforce; an effort to redesign primary care using registered nurses (RNs) practicing at the top of their education, license, and scope of practice; transforming public health to create healthy communities; and enhancing partnerships among academic nursing and academic health centers and other health-related organizations. The examination of research, evidence, context, and policy led to the creation of these four reports: the National Academy of Science’s “Viewpoint Series on Health and Health Care,” the Macy Foundation’s report on Registered Nurses in Primary Care, the Public Health Leadership Forum’s development of a briefing document for the next administration titled “Transforming Public Health and Health Care to Create Healthy Communities,” and the American Association of Colleges of Nursing’s report on “Advancing Healthcare Transformation.” These reports set the context for change and transformation in policy, practice, and education. In an earlier President’s message, I discussed the recommendations from the Macy Foundation’s report, and I will briefly review them again. The other three documents may be well known to some of you, and others may not be familiar. The American Academy of Nursing along with many other partners has been represented in all these efforts.
National Academy of Medicine: Vital Directions for Health and Health Care A series of 19 articles were written by teams of national experts under the auspices of the National Academy of
2
Nurs Outlook xxx (2016) 1e3
Medicine with the purpose of informing the next administration about opportunities to improve health and health care and reduce poor outcomes of the U.S. population. A synthesis of the articles was published in JAMA (National Academy of Medicine, 2016) with the full articles available on the National Academy of Science Web site (https://nam.edu/initiatives/vital-directionsfor-health-and-health-care/). The themes that emerged from these 19 articles included the following: Understanding that the determinants of health are the basis of health or illness and require a different type of approach and partnerships. In addition to health professionals including nurses, other partners required for this venture will include those from economics, business, housing, transportation, education, and many more. Advancing wellness and prevention is a necessary set of strategies that all populations need and are critical to assuring population health. Strong systems of care including access to health insurance and comprehensive care will require a redesign of the way care is provided, integrated, and paid for. The 21st century workforce will need to be prepared to work toward the protection and enhancement of health and health care and prepared for practice in both a person-centered and population-based health environment where it is understood that engagement of individuals and populations in care design and prevention is necessary. Continuous improvement in care and outcomes will occur through a system of metrics and measurement that enables us to realize progress on a range of health indicators, including the leading health indicators, county health rankings, and the vital signs core measure set that foster quality improvement and continuous learning.
RNs: Partners in Transforming Primary Care This work was led by the Macy Foundation in partnership with the American Academy of Nursing and prompted by an urgency to transform the design of primary health care so it becomes more integrated, multidisciplinary, population focused, and engaged in care over the life span of individuals and across care environments that serve populations. The primary recommendations that emerged from the final report included the following: Leaders of nursing schools, primary care practices, and health systems should actively facilitate culture change that elevates primary care in RN education and practice. Primary care practices should redesign their care models to use the skills and expertise of RNs in meeting the health care needs of patientsdand
payers and regulators should facilitate this redesign. Nursing schools’ leaders and faculty should elevate primary care content in the education of prelicensure and RN to Bachelor of Science in Nursing (BSN) nursing students. Leaders of primary care practices and health systems should facilitate lifelong education and professional development opportunities in primary care and support practicing RNs in pursuing careers in primary care. Academia and health care organizations should partner to support and prepare nursing faculty to educate prelicensure and RN to BSN students in primary care knowledge, skills, and perspective. Leaders and faculty in nursing education and continuing education programs should include interprofessional education and teamwork in primary care nursing curricula (Josiah Macy Foundation, 2016).
Transforming Public Health and Health Care to Create Healthy Communities Under the auspices of the Public Health Leadership Forum funded by the Robert Wood Johnson Foundation, a team of public health, academic, and policy leaders were convened to develop a report intended to inform the next Secretary of the U.S. Department of Health and Human Services (HHS) about priorities for transforming the nation’s health. The report proposed that the role of chief health strategist should be assumed by the HHS Secretary and lead a national initiative to assure that “America’s communities are places that provide every person with the opportunity to achieve optimal health and are served by a strong public health infrastructure” (DHHS, 2016). The committee found that a growing body of evidence indicated that: A healthy nation is achieved by more than what happens in public health agencies and the health care system but by what happens within and among diverse communities and is realized through partnerships across communities, sectors, and levels of government. A healthy nation is built through engaged communities with equitable access to opportunities and resources achieved across all communities and populations. A healthy nation assures equitable access to and engagement in quality physical and behavioral health services and that all, regardless of race, ethnicity, gender or gender identity, or sexual orientation are served by a robust public health system. A healthy nation is safe and secure from and able to respond to natural and human-made threats and disasters.
Nurs Outlook xxx (2016) 1e3
Given these findings, the committee recommended that state and local public health systems and HHS: Transform the health care and public health investments by the federal government into a health promoting system and adopt metrics that foster activities that support longer high-quality life and reduce health inequities. Assure communities have the data, evidence, analytic capacity and flexibility they need to build healthy and resilient communities including supporting cross-sector collaborations at the federal, state, and local levels. Assure every community is served by a wellresourced public health department that is accredited and able to provide foundational capabilities and respond to unanticipated emergencies.
Advancing Health Care Transformation This report of the American Association of Colleges of Nursing described recommendations for a new era for academic nursing. The report was commissioned to examine and enhance partnerships between academic nursing and academic health centers. It presented the possibility of transforming education and clinical settings that are focused on innovation, integration, and the utilization of evidence-based practice (American Association of Colleges of Nursing [AACN], 2015). Included among its recommendations were the following:
Enhance the clinical practice of academic nursing. Partner in preparing the nurses of the future. Partner in the implementation of accountable care. Invest in nursing research programs and better integrate research into clinical practice. Implement an advocacy agenda to support a new era for academic nursing.
3
take these messages to our policymakers and academic and clinical leaders to make the case that producing a healthy nation is essential to a productive and progressive society.
references
American Association of Colleges of Nursing (AACN). (2015). Advancing healthcare transformation: A new era for academic nursing. Retrieved from http://www.aacn.nche.edu/AACNManatt-Report.pdf The Department of Health and Human Services as the nation’s chief health strategist: Transforming public health and health care to create healthy communities (2016). Retrieved from http://www.resolv.org/site-healthleadershipforum/ files/2016/09/DHHS-as-the-Nations-Chief-Health-Strategistcolor.pdf Josiah Macy Jr. Foundation. (2016). Registered nurses: Partners in transforming primary care: Recommendations from the Macy Foundation Conference on preparing registered nurses for enhanced roles in primary care. Retrieved from http://macyfoundation. org/docs/macy_pubs/201609_Nursing_Conference_Exectuive_ Summary_Final.pdf National Academy of Medicine. (2016). Viewpoint series presenting highlights from the National Academy of Medicine’s vital directions for health and health care discussion paper series. Retrieved from http://jamanetwork.com/journals/jama/article-abstract/ 2544650
Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN President American Academy of Nursing Columbia University School of Nursing Columbia University Medical Center New York, NY Corresponding author: Bobbie Berkowitz, 630 West 168th Street, MC6, New York, NY 10032. E-mail address: [email protected] Available online xxx
These four reports are among many expressions of hope for a future health system that is transformational in the way we view and express health. But this future is not guaranteed and will require all of us to
0029-6554/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2016.12.007