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Later, when patients or families received a call from a nurse, they knew who that person was. As a result, an innovation that emerged when a few nurses at Geisinger took the initiative and changed an already well-established program to deliver more truly patient-centered care may now spread well beyond Pennsylvania.

Kaiser Permanente 10 , 11 As one of the largest not-for-profit health plans, Kaiser Permanente provides health care services for more than 8. Kaiser Permanente has facilities in nine states and the District of Columbia, and has 35 medical centers and medical offices. The system provides prepaid health plans that emphasize prevention and consolidated services designed to keep as many services as possible in one location KP, Nurses in San Diego have taken the lead in overseeing the process for patient discharge, making it more streamlined and efficient and much more effective.

They have created efficiencies relative to previous processes by using time-sensitive, prioritized lists of only those patients who are being discharged over the next 48 hours instead of patients who are being discharged weeks into the future.

Home health care nurses and discharge planners stay in close contact with one another on a daily basis to make quick decisions about patient needs, including the need for home health care visitation. In just 3 months, the number of patients who saw a home health care provider within 24 hours increased from 44 to 77 percent Labor Management Partnership, The model strengthens the patient-centered medical home concept and identifies members of the health care team HCT —a multidisciplinary group whose staff is centrally directed and physically located in small units within the medical office building.

The team serves panel management and comprehensive outreach and inreach functions to support primary care physicians and proactively manage the care of members with chronic conditions such as diabetes, hypertension, cardiovascular disease, asthma, osteoporosis, and depression.

Primary care management nurse clinic RNs and licensed practical nurses LPNs provide health care coaching and education for patients to promote self-management of their chronic conditions through face-to-face education visits and telephone follow-up.

Using evidence-based clinical guidelines, such as diabetes and hypertension treat-to-target algorithms, nurses play important roles in the promotion of changes in chronic conditions and lifestyles, coaching and counseling, self-monitoring and goal setting, depression screening, and the use of advanced technology such as interactive voice recognition for patient outreach. Through this model of care, nurses and pharmacists have become skilled users of health information technology to strengthen the primary care—based, patient-centered medical home.

Nurses use disease management registries to work with assigned primary care physicians, and review clinical information that addresses care gaps and evaluate treatment plans. RiPHM has provided a strong foundation for the patient-centered medical home. By implementing this program and expanding the role of nurses, Riverside has sustained continuous improvement in key quality indicators for patient care. Guided care is a new model for chronic care that was recently introduced within the Kaiser system.

Guided care is intended to provide, within a primary care setting, quality care to patients with complex needs and multiple chronic conditions. An RN, who assists three to four physicians, receives training in such areas as the use of an electronic health record EHR , interviewing, and the particulars of health insurance coverage.

Patients First! Engaging the Hearts and Minds of Nurses with a Patient-Centered Practice Model

RNs are also provided skills in managing chronic conditions, providing transitional care, and working with families and community organizations Boult et al. 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. Summary 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. 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. 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 professional resistance to expanded roles for nurses, fragmentation of the health care system, outdated insurance policies, high rates of nurse turnover, difficulties for nurses transitioning from school into practice, and an aging workforce and other demographic challenges. Many of these barriers have developed as a result of structural flaws in the U. Regulatory Barriers As the committee considered how the additional 32 million people covered by health insurance under the ACA would receive care in the coming years, it identified as a serious barrier overly restrictive scope-of-practice regulations for APRNs that vary by state.

The committee understands that physicians are highly trained and skilled providers and believes strongly that there clearly are services that should be provided by these health professionals, who have received more extensive and specialized education and training than APRNs. However, regulations in many states result in APRNs not being able to give care they were trained to provide. The committee believes all health professionals should practice to the full extent of their education and training so that more patients may benefit.

History of the Regulation of the Health Professions A paper commissioned by the committee 13 points out that the United States was one of the first countries to regulate health care providers and that this regulation occurred at the state—not the federal—level. Legislatively, physician practice was recognized before that of any other health profession Rostant and Cady, Most APRNs are in the opposite situation. At any point in their career, APRNs can do much more than they may legally do.

As APRNs acquire new skills, they must seek administrative or statutory revision of their defined scopes of practice a costly and often difficult enterprise. As the health care system has grown over the past 40 years, the education and roles of APRNs have continually evolved so that nurses now enter the workplace willing and qualified to provide more services than they previously did.

As the services supported by evolving education programs expanded, so did the overlap of practice boundaries of APRNs and physicians.

APRNs are more than physician extenders or substitutes. They cover the care continuum from health promotion and disease prevention to early diagnosis to prevent or limit disability. These services are grounded in and shaped by their nursing education, with its particular ideology and professional identity.

NPs also learn how to work with teams of providers, which is perhaps one of the most important factors in the successful care of chronically ill patients. Although they use skills traditionally residing in the realm of medicine, APRNs integrate a range of skills from several disciplines, including social work, nutrition, and physical therapy. Almost 25 years ago, an analysis by the Office of Technology Assessment OTA indicated that NPs could safely and effectively provide more than 90 percent of pediatric primary care services and 75 percent of general primary care services, while CRNAs could provide 65 percent of anesthesia services.

OTA concluded further that CNMs could be 98 percent as productive as obstetricians in providing maternity services Office of Technology Assessment, APRNs also have competencies that include the knowledge to refer patients with complex problems to physicians, just as physicians refer patients who need services they are not trained to provide, such as medication counseling, developmental screening, or case management, to APRNs.

Most NPs train in primary care; however, increasing numbers are being trained in acute care medicine and other specialty disciplines Cooper, The growing use of APRNs and physician assistants has helped ease access bottlenecks, reduce waiting times, increase patient satisfaction, and free physicians to handle more complex cases Canadian Pediatric Society, ; Cunningham, This is true of APRNs in both primary and specialty care.

In orthopedics, the use of APRNs and physician assistants is a long-standing practice. NPs and physician assistants in gastroenterology help meet the growing demand for colon cancer screenings in either outpatient suites or hospital endoscopy centers. Because APRNs and physician assistants in specialty practice typically collaborate closely with physicians, legal scope-of-practice issues pose limited obstacles in these settings. Variation in Nurse Practitioner Scope-of-Practice Regulations Regulations that define scope-of-practice limitations vary widely by state.


In some states, they are very detailed, while in others, they contain vague provisions that are open to interpretation Cunningham, However, the majority of state laws lag behind in this regard. As a result, what NPs are able to do once they graduate varies widely across the country for reasons that are related not to their ability, their education or training, or safety concerns Lugo et al.

For example, one group of researchers found that 16 states plus the District of Columbia have regulations that allow NPs to see primary care patients without supervision by or required collaboration with a physician see Figure As with any other primary care providers, these NPs refer patients to a specialty provider if the care required extends beyond the scope of their education, training, and skills. NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician.

Other legal practice barriers include on-site physician oversight requirements, chart review requirements, and maximum collaboration ratios for physicians who collaborate with more than a single NP. There are fundamental contradictions in this situation. Educational standards—which the states recognize—support broader practice by all types of APRNs. National certification standards—which most states also recognize—likewise support broader practice by APRNs.

Moreover, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question Brown and Grimes, ; Fairman, ; Groth et al. No studies suggest that care is better in states that have more restrictive scope-of-practice regulations for APRNs than in those that do not. Yet most states continue to restrict the practice of APRNs beyond what is warranted by either their education or their training.

Box provides an example of the variation in state licensure regulations, detailing examples of the services an APRN would not be permitted to provide if she practiced in a more restrictive state Safriet, In addition to variations among states, the scope of practice for APRNs in some cases varies within a state by geographic location of the practice within the state or nature of the practice setting.

Several states permit APRNs to provide a broad list of services, such as independently examining patients, ordering and interpreting laboratory and other tests, diagnosing and treating illness and injury, prescribing more Current laws are hampering the ability of APRNs to contribute to innovative health care delivery solutions.

Some NPs, for example, have left primary care to work as specialists in hospital settings Cooper, , although demand in those settings has also played a role in their movement. Others have left NP practice altogether to work as staff RNs. For example, restrictive state scope-of-practice regulations concerning NPs have limited expansion of retail clinics, where NPs provide a limited set of primary care services directly to patients Rudavsky et al.

Similarly, the roles of NPs in nurse-managed health centers and patient-centered medical homes can be hindered by dated state practice acts. Credentialing and payment policies often are linked to state practice laws.

A survey of the credentialing and reimbursement policies of managed care organizations revealed that 53 percent credentialed NPs as primary care providers; of these, 56 percent reimbursed primary care NPs at the same rate as primary care providers, and 38 percent reimbursed NPs at a lower rate Hansen-Turton et al. As discussed above, some states require NPs to be supervised by physicians in order to prescribe medications, while others do not.

In this survey, 71 percent of responding insurers credentialed NPs as primary care providers in states where there was no requirement for physicians to supervise NPs in prescribing medications. In states that required more physician involvement in NP prescribing, insurers were less likely to credential NPs. Of interest, this was the case even though the actual level of involvement by the physician may be the same in states where supervision is required as in states where it is not.

Also of note is that Medicaid plans were more likely than any other category of insurer to credential NPs.

Although there is a movement away from a fee-for-service system, Table shows the current payment structure for those providing primary care. The Federal Government and Regulatory Reform 16 Precisely because many of the problems described in this report are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption.

The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs such as Medicare, Medicaid, the VA, and the Bureau of Indian Affairs. Federal actors already play a central role in a number of areas that would be essential to effective reform of nursing practice, especially that of APRNs. They pay for the majority of health care services delivered today, they pay for research on the safety and effectiveness of existing and innovative practice models and encourage their adoption, and they have a compelling interest in achieving more efficient and value-driven health care services.

The federal government also appropriates substantial funds for the education and training of health care providers, and it has an understandable interest in ensuring that the ever-expanding skills and abilities acquired by graduates of these programs are fully utilized for the benefit of the American public.

Critical Thinking: The Development of an Essential Skill for Nursing Students

In particular, the Federal Trade Commission FTC has a long history of targeting anticompetitive conduct in health care markets, including restrictions on the business practices of health care providers, as well as policies that could act as a barrier to entry for new competitors in the market.

The FTC has responded specifically to potential policies that might be viewed predominantly as guild protection rather than consumer protection, for example, taking antitrust actions against the American Medical Association AMA for policies restricting access to clinical psychologists to cases referred by a physician and for ethical prohibitions on collaborating with chiropractors, podiatrists, and osteopathic physicians.

The Board had prohibited nondentists from providing teeth-whitening services. The FTC alleged that by doing this the Board had hindered competition and made it more difficult and costly for consumers in the state to obtain this service.

Principles of equity would suggest that this subscriber choice would be promoted by policies ensuring that full, evidence-based practice is permitted for all providers regardless of geographic location. Finally, the Centers for Medicare and Medicaid Services CMS has the responsibility to promulgate rules and policies that promote access of Medicare and Medicaid beneficiaries to appropriate care. CMS therefore should ensure that its rules and polices reflect the evolving practice abilities of licensed providers, rather than relying on dated definitions drafted at a time when physicians were the only authorized providers of a wide array of health care services.

Expanding Scopes of Practice for Nurses For several decades, the trend in the United States has been toward expansion of scope-of-practice regulations for APRNs, but this shift has been incremental and variable. Most recently, the move to expand the legal authority of all APRNs to provide health care that accords with their education, training, and competencies appears to be gathering momentum.

In , after 5 years of study, debate, and negotiation, a group of nursing accreditation, certification, and licensing organizations, along with several APRN groups, developed a consensus model for the education, training, and regulation of APRNs see Appendix D. The consensus document will help schools and programs across the United States standardize the education and preparation of APRNs.

It will also help state regulators establish consistent practice acts because of education and certification standardization. And of importance, this document reflects the consensus of nursing organizations and leaders and accreditation and certification boards regarding the need to eliminate variations in scope-of-practice regulations across states and to adopt regulations that more fully recognize the competence of APRNs.

Expanding the scope of practice for NPs is particularly important for the rural and frontier areas of the country. Twenty-five percent of the U. People who live in rural areas are generally poorer and have higher morbidity and mortality rates than their counterparts in suburban and urban settings, and they are in need of a reliable source of primary care providers NRHA, The case study in Box , describing an NP in rural Iowa, demonstrates the benefits of a broad scope of practice with respect to the quality of and access to care.

Promoting Access to Care in Rural Iowa The passage of the Affordable Care Act will give millions of Americans better access to primary care—if there are enough providers. The United States has a more Expansions include procedure-based skills involving, for example, IVs and cardiac outputs , as well as clinical judgment skills e.

On the other hand, given the projected nursing shortage, task shifting to overworked nurses could create unsafe patient care environments, especially in acute care hospitals. To avert this situation, nurses need to delegate to others, such as LPNs, nursing assistants, and community health workers, among others. A transformed nursing education system that is able to respond to changes in science and contextual factors, such as population demographics, will be able to incorporate needed new skills and support full scopes of practice for non-APRNs to meet the needs of patients see Chapter 4.

Rather the model needed to reflect the concerns and needs of the nurse and the Institute as well as the patient. This recognition prompted us to combine nursing care theories with broader-based management theories to achieve complete coverage of identified issues. The work of four theorists, Senge, Greenleaf, Manthey, and Benner, were key to the formation of the model as described below.

Shared vision. Senge described learning organizations as The primary objective of a nursing practice model needs to be communicating a shared vision that helps nurses manage changes in their practice and maintain their patient focus. These practices have become common concepts in nursing today.

While all health systems may appear to be learning organizations, many are being forced to behave in a manner similar to a learning organization because of external influences or events.

A rapid evolution in practice, caused by technological growth and abrupt changes due to regulation and payout revisions, has forced modern health systems to react and learn new methods quickly.

Without a shared vision the workforce may feel lost and efforts can be unfocused and less effective when exogenous events, i. Framework of care. The shared vision of the Cleveland Clinic nursing practice model was based on three concepts, namely serving leader, relationship-based care, and thinking in action. This descriptor was used because these three attributes together support a patient- and family-centered care model.

The three concepts are detailed below. Understanding the serving leader concept helps nurses guide patients in directing their own care. Serving leader. Although almost every nurse acts as a leader in some manner, this role is often hard to understand in a patient-centered environment. Nurses are required to allow patients to direct their own care as much as possible, yet patients and families are unfamiliar with this role and need time and training to accomplish it Institute for Patient-and Family-Centered Care, In , Greenleaf introduced the concept of a servant leader which defines this role for the nurses.

A serving leader is a leader who is concerned for the growth of the people he is serving Greenleaf, The Cleveland Clinic Experience is a patient-focused program that educates all employees in the concepts of quality, innovation, teamwork, service, integrity, and compassion.

Serving leadership is the template that all employees are expected to use in interactions with patients, families, and other employees.

The characteristics of the serving leader are: visionary, humility, accountability and drive, leadership, and develops self and others. Relationship-based care. The most important aspect of developing a practice model for nurses was clarifying and simplifying the role of individual caregivers. This required not only defining the relationship between patients, families, and other team members, but also identifying how the nurse should attempt to deliver care and support.

The serving leader training that every Cleveland Clinic nurse receives prepares them for assuming this role. Thinking in action. Providing expert guidance in ongoing care delivery was another important requirement.

The diverse care needs of the patient population at the Cleveland Clinic meant that the nursing practice model could act as no more than a general guide to care delivery. Heal me. Be nice to me. The many nursing actions needed to achieve the shared vision and execute the Framework of Care for nursing were summarized into four Domains of Nursing Practice. While every nurse will participate in every domain to some extent, individual nurses can select their sphere s of focus for their particular role and can identify their own goals for professional and personal growth.

The four domains consist of practice items with which every nurse is familiar. These domains and their areas of emphasis are described in Figure 3. Each domain is also discussed below. Quality and patient safety.

Continual emphasis on patient safety is directly rewarded at the Cleveland Clinic as research shows strong improvements with increased professional commitment to patient safety Teng, An example of our dashboard is shown in Figure 4. Healing environment. More than years ago Florence Nightingale noted the importance of the environment in her book Notes on Nursing Nightingale, Today we see a growing body of research that clearly demonstrates the benefits of a healing environment.

At the Cleveland Clinic, nurses are tasked with maintaining a healing environment that delivers the empathy, care, and compassion that patients and families need to promote healing.

To aid nurses in achieving this healing environment, we have developed a list of factors that contribute to a healing environment. It should be noted that this is only a partial listing as a healing environment is in large part a matter of attitude and circumstance. Research and evidence-based practice.

Research and evidence-based practice were combined into one domain as they are integrated and intertwined at the Cleveland Clinic. There is a specific Department of Nursing Research and Innovation reflecting the reality that research is a component that can lead to significant innovation in evidence-based practice French, Individual nurses or teams of nurses are responsible for identifying potential practice improvements and developing evidence-based research to validate these potential improvements.

The Department of Nursing Research and Innovation helps to guide nurses through the process of conducting research studies and disseminating these findings, along with other best practices. Practice counsels are also used to spread best practices throughout the organization to provide consistent care across the continuum.

Professional development and education. All nurses need continuing education. Additionally there are many opportunities for advanced education that will lead to improved patient care, career advancement, and personal satisfaction. Quantifiable data from on-screen simulations and math assessments round out individual nurse profiles and help develop excellence in patient care.

Nursing Books

Interdisciplinary simulations provided in simulation labs and onsite by the Cleveland Clinic Education Institute give care givers the ability to practice and perfect team work, collaboration, and technical skills. Model Tools Once the basic content of the models as described above had been identified, the Cleveland Clinic Marketing and Communications Department, along with an outside marketing and program development expert the second author of this article were enlisted to help organize and refine the concepts and aid in developing visual representations, tools, and presentations.

The Cleveland Clinic already had in use a number of visual logos, symbols, and themes that the CChs Practice Model Steering Committee wanted to maintain.

Figure 2a: Nursing Practice Model Nursing practice model. Centering the Patients First guiding principle in the hand holding globe image was unanimously accepted as a starting point for the practice model imagery. Various layouts and wording were developed, reviewed, and revised to clarify the concept of a shared vision for the four domains of the Framework of Care.

The hand became the representation of the shared vision, the Framework of Care was contained in a circle around the globe, and the four domains were the four quadrants of the globe as shown in the model in Figure 2a. A brochure was developed that showed the model along with the detailed elements of each domain Figure 5.In addition to variations among states, the scope of practice for APRNs in some cases varies within a state by geographic location of the practice within the state or nature of the practice setting.

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