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The Future of Nursing: Leading Change, Advancing Health
The Future of Nursing
LEADING CHANGE, ADVANCING HEALTH
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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The Future of Nursing: Leading Change, Advancing Health
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. 65815 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine.
The future of nursing : leading change, advancing health / Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-309-15823-7 (hardcover) — ISBN 978-0-309-15824-4 (pdf)
1. Nursing—Practice—United States. 2. Nursing—United States. 3. Leadership—United States. I. Robert Wood Johnson Foundation. II. Institute of Medicine (U.S.) III. Title.
[DNLM: 1. Nursing—trends—United States. 2. Education, Nursing—United States. 3. Health Policy—United States. 4. Leadership—United States. 5. Nurse's Role—United States. WY 16 AA1]
RT86.7.C65 2011
610.73—dc22
2010052816
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Cover credit: Photos reprinted with permission from Tom Semkow; Gregory Benson; Lisa Hollis, Cedars-Sinai Medical Center; and Sam Kittner/kittner.com.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press.
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The Future of Nursing: Leading Change, Advancing Health
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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The Future of Nursing: Leading Change, Advancing Health
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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The Future of Nursing: Leading Change, Advancing Health
COMMITTEE ON THE ROBERT WOOD JOHNSON FOUNDATION INITIATIVE ON THE FUTURE OF NURSING, AT THE INSTITUTE OF MEDICINE
DONNA E. SHALALA (Chair), President,
University of Miami, Coral Gables, FL
LINDA BURNES BOLTON (Vice Chair), Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA
MICHAEL R. BLEICH, Dean and Dr. Carol A. Lindeman Distinguished Professor, Vice Provost for Inter-professional Education and Development Oregon Health & Science University School of Nursing,
Portland
TROYEN A. BRENNAN, Executive Vice President, Chief Medical Officer,
CVS Caremark, Woonsocket, RI
ROBERT E. CAMPBELL, Vice Chairman (retired),
Johnson & Johnson, New Brunswick, NJ
LEAH DEVLIN, Professor of the Practice,
University of North Carolina at Chapel Hill School of Public Health, Raleigh
CATHERINE DOWER, Associate Director of Research,
Center for the Health Professions, University of California, San Francisco
ROSA GONZALEZ-GUARDA, Assistant Professor,
School of Nursing and Health Studies, University of Miami, Coral Gables, FL
DAVID C. GOODMAN, Professor of Pediatrics and of Health Policy, and Director,
Center for Health Policy Research, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
JENNIE CHIN HANSEN, Chief Executive Officer,
American Geriatrics Society, New York
C. MARTIN HARRIS, Chief Information Officer,
Cleveland Clinic, OH
ANJLI AURORA HINMAN, Certified Nurse-Midwife,
Intown Midwifery, Atlanta, GA
WILLIAM D. NOVELLI, Distinguished Professor,
McDonough School of Business, Georgetown University, Washington, DC
LIANA ORSOLINI-HAIN, Nursing Instructor,
City College of San Francisco, CA
YOLANDA PARTIDA, Director,
National Center, Hablamos Juntos, and
Assistant Adjunct Professor,
Center for Medical Education and Research, University of California, San Francisco, Fresno
ROBERT D. REISCHAUER, President,
The Urban Institute, Washington, DC
JOHN W. ROWE, Professor,
Mailman School of Public Health, Department of Health Policy and Management, Columbia University, New York
BRUCE C. VLADECK, Senior Advisor,
Nexera Consulting, New York
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The Future of Nursing: Leading Change, Advancing Health
Project Staff
SUSAN HASSMILLER, Study Director
ADRIENNE STITH BUTLER, Senior Program Officer
ANDREA M. SCHULTZ, Associate Program Officer
KATHARINE BOTHNER, Research Associate
THELMA L. COX, Administrative Assistant
TONIA E. DICKERSON, Senior Program Assistant
GINA IVEY, Communications Director
LORI MELICHAR, Research Director
JULIE FAIRMAN, Distinguished Nurse Scholar-in-Residence
JUDITH A. SALERNO, Executive Officer,
IOM
Consultants
CHRISTINE GORMAN, Technical Writer
RONA BRIERE, Consultant Editor
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The Future of Nursing: Leading Change, Advancing Health
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
John Benson, Jr., University of Nebraska Medical Center
Bobbie Berkowitz, University of Washington
George Boggs, American Association of Community Colleges
Marilyn P. Chow, Kaiser Permanente
Jordan J. Cohen, The George Washington University
Nancy W. Dickey, Texas A&M Health Science Center
Tine Hansen-Turton, National Nursing Centers Consortium and Public Health Management Corporation
Ann Hendrich, Ascension Health
Beverly Malone, National League for Nursing
Edward O’Neil, Center for the Health Professions, University of California, San Francisco
Robert L. Phillips, Jr., Robert Graham Center
Joy Reed, North Carolina Department of Health and Human Services
Thomas Ricketts, University of North Carolina School of Public Health
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Vinod Sahney, Institute for Healthcare Improvement
Charlotte Yeh, AARP Services Incorporated
Heather Young, Betty Irene Moore School of Nursing, University of California, Davis
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine Gebbie, School of Nursing, Hunter College City University of New York and Mark R. Cullen, Stanford University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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The Future of Nursing: Leading Change, Advancing Health
Foreword
The founding documents of the Institute of Medicine (IOM) call for experts to discuss, debate, and examine possible solutions for the multitude of complex health concerns that face the United States and the world. Equally important is the timely implementation of those solutions in a way that improves health. The United States is at an important crossroads as health care reforms are being carried out and the system begins to change. The possibility of strengthening the largest component of the health care workforce—nurses—to become partners and leaders in improving the delivery of care and the health care system as a whole inspired the IOM to partner with the Robert Wood Johnson Foundation (RWJF) in creating the RWJF Initiative on the Future of Nursing, at the IOM. In this partnership, the IOM and RWJF were in agreement that accessible, high-quality care cannot be achieved without exceptional nursing care and leadership. By working together, the two organizations sought to bring more credibility and visibility to the topic than either could by working alone. The organizations merged staff and resources in an unprecedented partnership to explore challenges central to the future of the nursing profession.
To support this collaborative effort, the IOM welcomed staff from RWJF, as loaned employees, to provide specific content expertise in nursing, research, and communications. Combining staff from two different organizations was an experiment that integrated best practices from both organizations and inspired us to think in fresh ways about how we conduct our work. We are indebted to RWJF for the leadership, support, and partnership that made this endeavor possible.
I am deeply grateful to the committee—led by Donna Shalala, committee chair and former Secretary of the Department of Health and Human Services, and Linda Burnes Bolton, committee vice chair—and to the staff, especially Susan
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Hassmiller, Adrienne Stith Butler, Andrea Schultz, and Katharine Bothner, who produced this report. Their work will serve as a blueprint for how the nursing profession can transform itself into an ever more potent and relevant force for lasting solutions to enhance the quality and value of U.S. health care in ways that will meet the future health needs of diverse populations. The report calls on nurses, individually and as a profession, to embrace changes needed to promote health, prevent illness, and care for people in all settings across the lifespan. The nursing profession cannot make these changes on its own, however. The report calls for multisector support and interprofessional collaboration. In this sense, it calls on all health professionals and health care decision makers to work with nurses to make the changes needed for a more accessible, cost-effective, and high-quality health care system.
Since its foundation 40 years ago, the IOM has produced many reports echoing the theme of high-quality, safe, effective, evidence-based, and patient-centered care. The present report expands on this theme by addressing the critical role of nursing. It demonstrates that achieving a successful health care system in the future rests on the future of nursing.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
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Preface
This report is being published at a time of great opportunity in health care. Legislation passed in March 2010 will provide insurance coverage for 32 million more Americans. The implications of this new demand on the nation’s health care system are significant. How can the system accommodate the increased demand while improving the quality of health care services provided to the American public?
Nursing represents the largest sector of the health professions, with more than 3 million registered nurses in the United States. The question presented to the committee that produced this report was: What roles can nursing assume to address the increasing demand for safe, high-quality, and effective health care services? In the near term, the new health care laws identify great challenges in the management of chronic conditions, primary care (including care coordination and transitional care), prevention and wellness, and the prevention of adverse events (such as hospital-acquired infections). The demand for better provision of mental health services, school health services, long-term care, and palliative care (including end-of-life care) is increasing as well. Whether improvements in all these areas of care will slow the rate of growth in health care expenditures remains to be seen; however, experts believe they will result in better health outcomes.
What nursing brings to the future is a steadfast commitment to patient care, improved safety and quality, and better outcomes. Most of the near-term challenges identified in the health care reform legislation speak to traditional and current strengths of the nursing profession in such areas as care coordination, health promotion, and quality improvement. How well nurses are trained and do their jobs is inextricably tied to most health care quality measures that have been
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The Future of Nursing: Leading Change, Advancing Health
APPENDIXES*
A
Methods and Information Sources
285
B
Committee Biographical Sketches
307
C
Highlights from the Forums on the Future of Nursing
315
D
APRN Consensus Model
323
E
Undergraduate Nursing Education
369
F
Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Not Past Demands
375
G
Transformational Models of Nursing Across Different Care Settings
401
H
Federal Options for Maximizing the Value of Advanced Practice Nurses in Providing Quality, Cost-Effective Health Care
443
I
The Future of Nursing Education
477
J
International Models of Nursing
565
INDEX
643
*
Appendixes F–J are not printed in this report but can be found on the CD-ROM in the back of this book.
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The Future of Nursing: Leading Change, Advancing Health
Tables, Figures, and Boxes
TABLES
1-1
Types of Advanced Practice Registered Nurses (APRNs),
26
1-A1
Providers of Nursing Care: Numbers, Preparation/Training, and Roles,
43
1-A2
Pathways in Nursing Education,
44
3-1
Complexity of Evaluation and Management Services Provided Under Medicare Claims Data for 2000, by Practitioner Type,
90
3-2
Medicare Claims Payment Structure by Provider Type,
104
3-3
Plans Regarding Nursing Employment, by Graduation Cohort, 2008,
119
3-4
Changes in Position Setting, by 2007 Setting, for Registered Nurses Who Graduated in 2001–2008,
11
3-A1
State-by-State Regulatory Requirements for Physician Involvement in Care Provided by Nurse Practitioners,
157
4-1
Average Earnings of Full-Time RNs, by Highest Nursing or Nursing-Related Education and Job Title,
172
4-2
Years Between Completion of Initial and Highest RN Degrees,
187
4-3
Average Annual Earnings of Nurses Who Work Full Time as Faculty in Their Principal Nursing Position, 2008,
187
4-4
Average Earnings by Job Title of Principal Position for Nurses Working Full Time,
188
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4-5
Estimated Distribution of Master’s and Doctoral Degrees as Highest Nursing or Nursing-Related Educational Preparation, 2000–2008,
19
E-1
Demographic and Educational Characteristics of Registered Nurses, by Age,
370
J-1
NCLEX Examination Statistics, 2007,
575
J-2
Titles of Nursing Personnel from Select Countries,
577
J-3
Historic Suppliers of Registered Nurses to the U.S. Workforce,
608
J-4
Emerging Suppliers of Registered Nurses to the U.S. Workforce,
621
FIGURES
1-1
Employment settings of registered nurses,
24
1-2
Employment settings of RNs, by highest nursing or nursing-related education,
25
3-1
Map of the number of NPs per primary care MD by county, 2009,
89
3-2
Map of the number of physician assistants per primary care MD by county, 2009,
89
3-3
Requirements for physician–nurse collaboration, by state, as a barrier to access to primary care,
99
3-4
Physician opinions about the impact of allowing nurse practitioners to practice independently,
113
3-5
Patient satisfaction with retail-based health clinics,
113
3-6
Reasons cited for not working in nursing, by age group,
118
3-7
Age distribution of registered nurses, 1980–2008,
12
3-8
Average age of nurses at various levels of education and of MDs,
127
3-9
Distribution of registered nurses and the U.S. population by racial/ethnic background,
129
4-1
Trends in graduations from basic RN programs, by type, 2002–2008,
16
4-2
Highest nursing or nursing-related education by urban/rural residence,
178
4-3
Distance between nursing education program and workplace for early-career nurses (graduated 2007–2008),
17
4-4
Numbers of qualified applicants not accepted in ADN and BSN programs,
182
4-5
Age distribution of nurses who work as faculty,
183
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4-6
Distribution of the registered nurse population by highest nursing or nursing-related educational preparation,
1980–2008, 18
4-7
Growth trends in different nursing programs,
196
4-8
Percentage of minority students enrolled in nursing programs by race/ethnicity and program type, 2008–2009,
20
5-1
Opinion leaders’ predictions of the amount of influence nurses will have on health care reform,
240
5-2
Opinion leaders’ views on the amount of influence nurses should have on various areas of health care,
241
6-1
Forecast supply of and demand for full-time equivalent (FTE) RNs, 2009–2030,
25
6-2
Trends in new licenses, U.S.- and foreign-educated RNs, 2002–2008,
26
6-3
Factors to consider when assessing the health care workforce supply,
263
6-4
Factors to consider when assessing health care workforce demand,
263
D-1
APRN Regulatory Model,
333
D-2
Relationship Among Educational Competencies, Licensure, & Certification in the Role/Population Foci and Education and Credentialing in a Specialty,
339
F-1
RN-to-population ratio, 1980–2008,
38
F-2
Geographic variation in rates of hospital-based RNs per 1,000 population (2006),
388
BOXES
P-1
Committee Charge,
xiii
S-1
Committee Charge,
3
2-1
Case Study: When Patients and Families Call a Code,
52
2-2
Case Study: Nurse Midwives and Birth Centers,
56
2-3
Nurse Profile: Carolina Sandoval,
60
2-4
Nurse Profile: Lisa Ayers,
62
2-5
Case Study: Living Independently for Elders (LIFE),
68
2-6
Case Study: The Transitional Care Model,
70
2-7
Case Study: The Nurse–Family Partnership,
73
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3-1
Variation in State Licensure Regulations,
100
3-2
Case Study: Advanced Practice Registered Nurses,
108
3-3
Case Study: The Patient-Centered Medical Home,
134
3-4
Case Study: 11th Street Family Health Services of Drexel University,
138
3-5
Case Study: Technology at Cedars-Sinai Medical Center,
146
4-1
Costs of Health Professional Education,
169
4-2
Case Study: The Oregon Consortium for Nursing Education (OCNE),
174
4-3
Case Study: Community Colleges Offering the BSN,
180
4-4
Nurse Profile: Jennifer Wenzel*,
184
4-5
Case Study: The Dedicated Education Unit,
192
4-6
Case Study: Nursing for Life—The RN Career Transition Program,
204
5-1
Results of Gallup Poll “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,”
224
5-2
Case Study: Arkansas Aging Initiative,
226
5-3
Nurse Profile: Connie Hill,
230
5-4
Nurse Profile: Kenya D. Haney and Billy A. Caceres,
232
5-5
Nurse Profile: Mary Ann Christopher,
236
5-6
Case Study: Prescription for Pennsylvania,
248
7-1
Research Priorities for Transforming Nursing Practice,
274
7-2
Research Priorities for Transforming Nursing Education,
276
7-3
Research Priorities for Transforming Nursing Leadership,
277
A-1
Technical Workshop #1,
292
A-2
Technical Workshop #2,
293
A-3
Technical Workshop #3,
294
A-4
Forum on the Future of Nursing: Acute Care,
295
A-5
Forum on the Future of Nursing: Care in the Community,
296
A-6
Forum on the Future of Nursing: Education,
298
A-7
Testimony Questions for the Forum on the Future of Nursing: Acute Care,
300
A-8
Testimony Questions for the Forum on the Future of Nursing: Care in the Community,
302
A-9
Testimony Questions for the Forum on the Future of Nursing: Education,
304
*
This nurse profile was inadvertently omitted from the prepublication version of this report.
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F-1
RN Ambulatory Care Workforce,
383
F-2
Processes and Policy Initiatives Producing Health Care Workforce Skill Mix Changes,
393
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Acronyms and Abbreviations*
AACN American Association of Colleges of Nursing
AAI Arkansas Aging Initiative
AAMC Association of American Medical Colleges
AARP American Association of Retired Persons
ACA Affordable Care Act
ACO accountable care organization
ADN associate’s degree in nursing
AIDS acquired immune deficiency syndrome
AMA American Medical Association
ANA American Nurses Association
ANCC American Nurses Credentialing Center
AONE American Organization of Nurse Executives
APRN advanced practice registered nurse
ARRA American Recovery and Reinvestment Act
BSN bachelor’s of science in nursing
CBO Congressional Budget Office
CCNE Commission on Collegiate Nursing Education
CHC community health center
CMA California Medical Association
CMS Centers for Medicare and Medicaid Services
*
The acronyms and abbreviations used in the Summary and Chapters 1–7 appear in this list.
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CNA certified nursing assistant
CNL clinical nurse leader
CNM certified nurse midwife
CNO chief nursing officer
CNS clinical nurse specialist
CRNA certified registered nurse anesthetist
CSA California Society of Anesthesiologists
DEU dedicated education unit
DNP doctor of nursing practice
DRG diagnosis-related group
EHR electronic health record
FHBC Family Health and Birth Center
FQHC federally qualified health center
FTC Federal Trade Commission
FTE full-time equivalent
GAO Government Accountability Office
GCHSSC Gulf Coast Health Services Steering Committee
HealthSTAT Health Students Taking Action Together
HEET Hospital Employee Education and Training
HHS Health and Human Services
HIT health information technology
HIV human immunodeficiency virus
HNC Harambee Nursing Center
HRSA Health Resources and Services Administration
ICU Intensive Care Unit
IHI Institute for Healthcare Improvement
INLP Integrated Nurse Leadership Program
INQRI Interdisciplinary Nursing Quality Research Initiative
IOM Institute of Medicine
LIFE Living Independently for Elders
LPN/LVN licensed practical nurse/licensed vocational nurse
MD medical doctor
MedPAC Medicare Payment Advisory Commission
MSN master’s of science in nursing
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NA nursing assistant
NAQC Nursing Alliance for Quality Care
NASN National Association of School Nurses
NCEMNA National Coalition of Ethnic Minority Nurse Associations
NCLEX-RN National Council Licensure Examination for Registered Nurses
NCQA National Committee for Quality Assurance
NCSBN National Council of State Boards of Nursing
NFP Nurse–Family Partnership
NHIT national health care information technology
NHWC National Health Workforce Commission
NLN National League for Nursing
NMHC nurse-managed health clinic
NNCC National Nursing Centers Consortium
NP nurse practitioner
NQF National Quality Forum
NRN Nursing Research Network
NSNA National Student Nurses Association
NSSRN National Sample Survey of Registered Nurses
OCNE Oregon Consortium for Nursing Education
OHSU Oregon Health and Science University
OPM Office of Personnel Management
PACE Program of All-Inclusive Care for the Elderly
PCMH Patient-Centered Medical Home™
PhD doctor of philosophy
RN registered nurse
RWJF Robert Wood Johnson Foundation
SAMHSA Substance Abuse and Mental Health Services Administration
SEIU Service Employees International Union
SOPP Scope of Practice Partnership
TCAB Transforming Care at the Bedside
TCM Transitional Care Model
TIGER Technology Informatics Guiding Education Reform
TWU Texas Woman’s University
UAMS University of Arkansas for Medical Sciences
UHC University HealthSystem Consortium
UP University of Portland
UPMC University of Pittsburgh Medical Center
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USF University of South Florida
UTH University of Texas Health Science Center at Houston School of Nursing
VA Department of Veterans Affairs
VANA Veterans Affairs Nursing Academy
VNACJ Visiting Nurse Association of Central Jersey
VNSNY Visiting Nurse Service of New York
