sponses that support the diversion of RNs to hospitals and setting-specific models of nursing practice.

Growing RN primary care capacity in response to the anticipated rise in demand for care from increased coverage will require overcoming significant hurdles in the preparation and deploying of RNs to the full array of ambulatory care settings. Retooling nursing education and revamping working conditions and salaries in ambulatory care will be needed to stem the flow of nurses to hospitals, both RN as well as advanced practice nurses. The growing evidence of the influence of prolonged hours of interns and residents on medical errors and adverse events has led to the introduction of regulations limiting their hours. This “shortfall” in medical resident hours has stimulated a demand for, and a gradual migration of, NPs to acute care settings. And while the shortage of primary care capacity would be expected to engender greater demand for all primary care providers including NPs, barriers to practice interfere with their full employment in ambulatory care. Even in states where state practice acts allow NPs to practice fully and independently, the demand for NPs has been constrained by health plan practices (e.g., failure to be credentialed as primary care providers) and reimbursement policies.

Getting the RN workforce required to support health care delivery reform will require a wholesale paradigm shift in the framework and context used to prepare and deploy the RN workforce and to forecast future requirements. This shift will be predicated on the degree to which the implementation of the health reform legislation “recalibrates” the demand for RNs. Payment reform that rewards effective coordination of care over inefficient use of acute inpatient services will demand RNs with skills in care management particularly for the complexly chronically ill, transitional care and community-based services. Payment reform that promotes the creation of medical homes will demand the production of RNs who can provide and direct interdisciplinary teams in the provision of primary care services. Accountable care organizations that are responsible for the full range of health needs of defined populations will demand RNs whose skills span from primary care to end-of-life care and who practice follows the patient and family/caregivers across the full range of settings including the home. And all of these innovations will require fully integrated, interoperable HIT that will support health care teams in ways that are likely affect the effective use of all of their members.

The challenges to achieving this RN workforce in the future are grouped in three general categories. The first challenge lies in the health care marketplace. Currently nurses are hired by employers to fill vacant positions rather than to provide specific skills, perpetuating an employment pattern that is insensitive to different and potentially more efficient skill mix configurations. The health care marketplace, and payers in particular, have not offered sufficient incentives for health care employers to demand a nursing workforce that aligns the skills of RNs more effectively with needs of patients and the health care system. There



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