is an integral component of ACOs to provide quality and cost benchmarks and progress, and to ensure that cost control is not achieved through by limiting necessary or appropriate care.

ACOs will depend on several structural and organizational features in order to meet their cost and quality targets. Fully integrated electronic health records (EHRs) and other types of HIT would be required for timely and meaningful information sharing across the entire range of providers. Regular feedback on performance and benchmarks will need to be shared with all providers, services and enrollees in the ACOs. Moreover, ACOs will be supported and strengthened by adopting rigorous, evidence-based care management practices that are the foundation of many complementary system reforms, e.g., PCMHs and transitional care, to manage and guide the care of fully functioning teams of providers and to coordinate communication within and across teams, organizations, and disciplinary lines.

The care management and coordination strategies adopted by ACOs and other types of integrated delivery systems require an RN workforce that is linked to the patient, can readily transition with the patient across time and care settings and is ultimately accountable for outcomes that transcend time and place. RNs working in this context would be employed by the ACO, one of its practices or contracting care coordination organizations and would be responsible for care management for the most complexly ill patients in the group and for their care transitions. These transitions would include from hospital to home or other postacute setting, from home to hospital, or from ongoing primary care to intensive outpatient secondary care.

Expanding Primary Care Capacity

The demand to build the primary care nursing workforce—both RNs and advanced practice nurses—will grow as accessibility to coverage, service settings, and services increases. The Massachusetts experience provides evidence of this growth in demand: passage of health reform in 2006 led to a substantial increase in demand for primary care services only some of which could be met with the existing reservoir of primary care resources (Long, 2008; Long and Masi, 2009). Moreover, today the number of nurse practitioners (NPs) and physician assistants (PAs) rivals the number of family physicians delivering primary care; thus a substantial share of the growth in demand for primary care services that will follow the expansion in health coverage will by design fall on the shoulders of nurses (Green et al., 2004).

The growth in health centers during the prior decade provides some parameters for quantifying the growth in the demand for the primary care RN workforce. Between 2000 and 2006 the number of patients served by the nation’s health centers grew 67 percent, to 16 million. To meet the concomitant increase in demand for care, the number of primary care physicians at health centers grew by



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