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Introduction

On December 3, 2009, the Initiative on the Future of Nursing, a collaborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM), held a forum at the Community College of Philadelphia to examine the challenges facing the nursing profession with regard to care in the community, including aspects of community health, public health, primary care, and long-term care. The forum was the second of three held to gather information and discuss ideas related to the future of nursing. The first forum held October 19, 2009, at Cedars-Sinai Medical Center in Los Angeles, focused on the future of nursing in acute care. The third forum, on February 22, 2010, in Houston, examined the future of nursing education.

The forums have been part of an intensive information-gathering effort by an IOM committee that is the cornerstone of the Initiative on the Future of Nursing. The committee will use the information collected at these forums, at its two technical workshops, from data provided by the RWJF Nursing Research Network, and from a number of commissioned papers to inform the development of its findings, conclusions, and recommendations. The committee’s final recommendations will be presented in a report on the capacity of the nursing workforce to meet the demands of a reformed health care system.

Each of the three forums was planned with the guidance of a small group of committee members; the planning group for this forum was led by Ms. Jennie Chin Hansen. The half-day forums were not meant to be an exhaustive examination of all settings in which nurses practice or of the complexity of the nursing profession as a whole. Given the limited amount of time for each of the three forums, a comprehensive review of all facets and all players of each of the main forum themes was not pos-



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1 Introduction On December 3, 2009, the Initiative on the Future of Nursing, a col- laborative effort between the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM), held a forum at the Community College of Philadelphia to examine the challenges facing the nursing pro- fession with regard to care in the community, including aspects of com- munity health, public health, primary care, and long-term care. The forum was the second of three held to gather information and discuss ideas related to the future of nursing. The first forum held October 19, 2009, at Cedars-Sinai Medical Center in Los Angeles, focused on the future of nursing in acute care. The third forum, on February 22, 2010, in Houston, examined the future of nursing education. The forums have been part of an intensive information-gathering ef- fort by an IOM committee that is the cornerstone of the Initiative on the Future of Nursing. The committee will use the information collected at these forums, at its two technical workshops, from data provided by the RWJF Nursing Research Network, and from a number of commissioned papers to inform the development of its findings, conclusions, and rec- ommendations. The committee’s final recommendations will be pre- sented in a report on the capacity of the nursing workforce to meet the demands of a reformed health care system. Each of the three forums was planned with the guidance of a small group of committee members; the planning group for this forum was led by Ms. Jennie Chin Hansen. The half-day forums were not meant to be an exhaustive examination of all settings in which nurses practice or of the complexity of the nursing profession as a whole. Given the limited amount of time for each of the three forums, a comprehensive review of all facets and all players of each of the main forum themes was not pos- 1

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2 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY sible. Rather, the forums were meant to inform the committee on impor- tant topics within the nursing profession and to highlight some of the key challenges, barriers, opportunities, and innovations that nurses face while working in an evolving health care system. Many of the critical chal- lenges, barriers, opportunities, and innovations discussed at the forums overlap across settings and throughout the nursing profession and also are applicable to other providers and individuals who work with nurses. This summary of the forum on care in the community describes the main points made by speakers in their presentations and during the discussion and question-and-answer periods that followed, as well as points made by forum participants who offered testimony. A complete agenda of the forum can be found in Appendix B, and biosketches of the speakers can be found in Appendix C. The remaining sections of this chapter describe two activities that occurred in conjunction with the forum and also present the welcoming remarks of Pennsylvania Gover- nor Edward Rendell. Chapter 2 summarizes the talk of keynote speaker Mary C. Selecky. Chapters 3, 4, and 5 describe the remarks and answers to questions at sessions focused on community and public health, pri- mary care, and chronic and long-term care, respectively. Chapter 6 sum- marizes the oral testimony presented by 15 forum attendees, along with remarks made by forum participants during an open-microphone session at the end of the forum. Comments made at the forum should not be interpreted as positions of the committee, RWJF, IOM, or the Community College of Pennsyl- vania. Committee members’ questions and comments do not necessarily reflect their personal views or the conclusions that will be in the commit- tee’s report. However, the questions and comments were designed to elicit information and perspectives that can guide the committee’s delib- erations. SITE VISITS In the morning before the forum began, the committee members par- ticipated in a series of site visits throughout the city of Philadelphia to community and public health centers, some of which were nurse-led and managed. During the site visits they had the opportunity to talk with nurses, administrators, other health care providers, and patients about some of the challenges and innovative strategies that nurses are using in these settings to provide quality care in the community and expand ac-

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3 INTRODUCTION cess. Observations made during these site visits are not part of this sum- mary of the forum, but the site visits informed at least some of the ques- tions directed to speakers by committee members at the event. The six sites visited by committee members were the Living Independently for Elders (LIFE) program at the University of Pennsylvania School of Nurs- ing, the Sayre High School School-Based Health Clinic, Community Health Center #3 of the Philadelphia Department of Health, Health An- nex, Health Connections, and the 11th Street Family Health Services of Drexel University. Robert Wood Johnson Foundation Solutions Session After the forum, a select group of RWJF scholars and fellows hosted by RWJF met to discuss what they saw on the site visits and heard at the forum in the context of their own expertise, knowledge, and judgment. This session was independent of the IOM committee and the forum on the future of nursing. The goal of the session was to provide an opportu- nity for the fellows and scholars to consider solutions and the most prom- ising future roles for nurses in public health, community health, primary care, and long-term care. The solutions offered by the fellows and scholars are not described in this summary of the forum. However, summaries of their solutions were provided to the committee for its review and consideration at the com- mittee’s subsequent meeting in January 2010. FORUM WELCOME: A LABORATORY FOR HEALTH CARE REFORM The states have historically been laboratories for public policy, said Pennsylvania Governor Edward Rendell in his opening remarks at the forum. If new ideas are successful in one state, other states and the fed- eral government may adopt those ideas. States, including Pennsylvania, have played a particularly important role in experimenting with innova- tive health care reform strategies. When Rendell became governor of Pennsylvania in 2003, “there was no chance for comprehensive national health care reform and no guarantee that it would happen in the next dec- ade.” The state stepped into the breech by launching a comprehensive reform program called Prescription for Pennsylvania, which Rendell

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4 FORUM ON THE FUTURE OF NURSING: CARE IN THE COMMUNITY noted has become a model for the federal government in implementing national health care reform. The mission of Prescription for Pennsylvania, said Rendell, “was to ensure that every resident of Pennsylvania had access to quality, afford- able health care.” That meant dealing with issues of both access and cost, and one of the first things the state realized is that nurses could help re- solve both of those problems. The addition of a nurse practitioner to a medical practice can double the number of patients seen while maintain- ing the same level of quality and lowering costs (AANP, 2007). To take advantage of these savings and expand access to care, Pennsylvania broadened the scope of practice for nurse practitioners, allowing an ex- pansion of the number of clinics run by nurses in a variety of settings, including retail locations. Since Prescription for Pennsylvania moved forward, 41 retail clinics, employing 200 nurse practitioners, have opened up in Pennsylvania; these facilities are open seven days a week and have saved an estimated 150,000 emergency room visits, said Rendell. To make affordable health care available to all children, Pennsyl- vania has expanded the Children’s Health Insurance Program (CHIP) in an effort called Cover All Kids to provide coverage for families at higher income levels than are usually included in the program. “That is the way to expand access and make sure that the health care delivery system can be more and more affordable,” said Rendell. Under Prescription for Pennsylvania, the state also has enacted what Rendell called “the toughest health care infection law in the nation,” which includes no longer paying for hospital-acquired infections through Medicaid, implementation of quality management and error reducing systems, and reporting mandates for hospital-acquired infections. These infections used to cause an estimated 3,500 deaths a year in the state and extend the hospital stays of an additional 22,000 patients. These extended hospital stays increase the average cost per patient from $35,000 to about $150,000. During the first 5 months after the law was passed, hospital- acquired infections were reduced 7.8 percent, saving $328 million, said Rendell. In addition, Rendell noted that Pennsylvania has ceased paying through Medicaid for so-called never events—medical mistakes that should never have happened, such as amputation of the wrong limb. Pennsylvania also passed a law prohibiting health care providers from billing for never events. Avoiding such medical mistakes is another way to control costs in the health care delivery system.

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5 INTRODUCTION In 2006, 70 percent of seniors or other people living with disabilities were being treated in nursing homes across the state. With the help of nurse practitioners and physician assistants, the state has cut that number to 60 percent, said Rendell. A critical step in accomplishing this im- provement was reducing barriers to practice. For example, in Pennsyl- vania, nurse practitioners and physician assistants previously could not do such things as order medical equipment, make physical therapy and dietician referrals, order respiratory or occupational therapy, or make general referrals. Reducing barriers to practice was also critical for certi- fied nurse midwives. Until state laws were changed, Pennsylvania was the only state in the nation where certified nurse midwives could not pre- scribe drugs for their patients, even though 10 percent of all babies in the state are delivered by certified nurse midwives and in some areas they are the only source of prenatal and gynecological care. The state also has reformed its approach to chronic care, which ac- counts for 80 percent of all health care costs in hospitalizations, 76 per- cent of all physician visits, and 91 percent of all filled prescriptions. In examining initiatives in other states, Pennsylvania found evidence of ef- fectiveness in the Chronic Care Model that was developed by Edward Wagner, director of the Washington State McColl Institute for Health- care Innovation. This model emphasizes managing chronic diseases through a team-based approach. “The results of this new methodology have been startling,” said Rendell. Citing first-year results, Rendell noted that the number of diabetes patients who have lowered their LDL (low- density lipoprotein) cholesterol counts below 130 has increased 43 per- cent; the number of diabetes patients who have lowered their blood pres- sure below 140 over 90 has increased 25 percent; and the number of patients getting eye exams has gone up 71 percent. For diabetes in one Medicaid health maintenance organization (HMO), hospitalization costs are down 26 percent and emergency room costs are down by 18 percent during the first 10 months. “We can do this,” concluded Rendell. “Those who say that health care reform is too complicated, too difficult, . . . are dead wrong. They don’t know the secret weapon, though it shouldn’t be a secret much longer. The secret weapons for increasing access and increasing afforda- bility are nurses, nurse practitioners, and physician assistants.”

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