The nurse providing guided care offers eight services: assessment; planning care; monitoring; coaching; chronic disease self-management; educating and supporting caregivers; coordinating transitions between providers and sites of care; and facilitating access to community services, such as Meals-on-Wheels, transportation services, and senior centers. Results of a pilot study comparing surveys of patients who received guided care and those who received usual care revealed improved quality of care and lower health care costs (according to insurance claims) for guided care patients (Boult et al., 2008).


The VA, Geisinger, and Kaiser Permanente are large integrated care systems that may be better positioned than others to invest in the coordination, education, and assessment provided by their nurses, but their results speak for themselves. If the United States is to achieve the necessary transformation of its health care system, the evidence points to the importance of relying on nurses in enhanced and reconceptualized roles. This does not necessarily mean that large regional corporations or vertically integrated care systems are the answer. It does mean that innovative, high-value solutions must be developed that are sustainable, easily adopted in other locations, and rapidly adaptable to different circumstances. A website on “Innovative Care Models” illustrates that many other solutions have been identified in other types of systems.12 As patients, employers, insurers, and governments become more aware of the benefits offered by nurses, they may also begin demanding that health care providers restructure their services around the contributions that a transformed nursing workforce can make. As discussed later in the chapter, the committee believes there will be numerous opportunities for nurses to help develop and implement care innovations and assume leadership roles in accountable care organizations and medical homes as a way of providing access to care for more Americans. As the next section describes, however, it will first be necessary to acknowledge the barriers that prevent nurses from practicing to the full extent of their education and training, as well as to generate the political will on the part of policy makers to remove these barriers.


Nurses have great potential to lead innovative strategies to improve the health care system. As discussed in this section, however, a variety of historical, regulatory, and policy barriers have limited nurses’ ability to contribute to widespread transformation (Kimball and O’Neil, 2002). This is true of all RNs, including those practicing in acute care and public and community health settings, but is most notable for APRNs in primary care. Other barriers include

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