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The Future of Nursing: It s Up to Us Now

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2/28/2012 The Future of Nursing: It s Up to Us Now Catherine Dower Indianapolis March 3, 2012 My mom Catherine works at UCSF. She studies different doctor s offices around the US, and tries to improve
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2/28/2012 The Future of Nursing: It s Up to Us Now Catherine Dower Indianapolis March 3, 2012 My mom Catherine works at UCSF. She studies different doctor s offices around the US, and tries to improve their work and health laws through reports (oral, as well as written) Dower 100,000/25,000/10,000 #1 $ /190 ½ 4th-8th 17% 2700 million trillion 19/19 Explore with me what nursing s future may be in context of... Change drivers PPACA IOM Report UCSF Center for the Health Professions 1 MD/100K /28/2012 MD/100K 2008 Percent GDP to Health Care 20% 16.2% Change Drivers Costs 11.0% 10% 0% US EU Avg US % Bankruptcies due to Medical Bills Life Expectancy at Birth, US Demographic shifts Men Women US Population Growth Technology 36% 18% Source: US Census, 2008 Population Summary & 2010 Population Estimates 360 Consumers Market 178 Baicker & Chandra, Health Affairs 2004 UCSF Center for the Health Professions 2 2/28/2012 Patient Protection and Affordable Care Act Five ACA categories relate to our work Coverage Financing Innovations in Care Delivery Workforce Pay for quality Expand Coverage Workforce Supply and Demand Nurse Practitioners, 19% Physician Assistants, 7% Physicians, 74% Financing: Provider payment policies Internet searches for Accountable Care Organizations September 2010: 346,000 results January ,300,000 results October 2011: 4,200,000 results February 2012: 38,400,000 results Tying payment to quality UCSF Center for the Health Professions 3 2/28/2012 Innovative Practice Models Patient-Centered Medical/Health Homes Community Clinics Nurse-Managed Health Clinics School-based clinics Sites using telehealth IOM Report Committee s Vision The committee envisions a future system that makes quality care accessible to the diverse populations of the United States, intentionally promotes wellness and disease prevention, reliably improves health outcomes, and provides compassionate care across the lifespan. In this envisioned future, primary care and prevention are central drivers of the health care system. UCSF Center for the Health Professions 4 2/28/2012 Interprofessional collaboration and coordination are the norm. Payment for health care services rewards value, not volume of services, and quality care is provided at a price that is affordable for both individuals and society. The rate of growth of health care expenditures slows. In all these areas, the health care system consistently demonstrates that it is responsive to individuals needs and desires through the delivery of truly patient-centered care. 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 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 Interprofessional Education and Development Oregon Health and 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 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 David C. Goodman, Professor of Pediatric and of Community and Family Medicine, Children s Hospital at Dartmouth, The Dartmouth Institute for Policy and Clinical Practice, Hanover, NH Jennie Chin Hansen, Chief Executive Officer, American Geriatrics Society, New York, NY C. Martin Harris, Chief Information Officer, Cleveland Clinic, Cleveland, OH Anjli Aurora Hinman, Alumni Chair, Health Students Taking Action Together, Duluth, 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, UCSF Fresno Center for Medical Education and Research, Fresno, CA 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, NY Bruce C. Vladeck, Senior Advisor, Nexera Consulting, New York, NY Key Messages 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and an improved information infrastructure. Key Message #1. Nurses should practice to the full extent of their education and training. The variability of scope-of-practice regulations across states may hinder advanced practice nurses from giving care they were trained to provide and contributing to innovative health care delivery solutions. Although some states have regulations that allow nurse practitioners to see patients and prescribe medications without a physician s supervision, a majority of states do not. The federal government is well suited to promote reform of states scope-of-practice laws by sharing and providing incentives for the adoption of best practices. Scope of practice laws are statebased and politically driven resulting in state variability and unnecessary limitations on practice. UCSF Center for the Health Professions 5 2/28/2012 Best example of poor match in US is NPs Requirements for physician nurse collaboration, No MD Involvement No MD Involvement except for Rx MD Supervision & collaboration 10 MD Supervision 3 7 MD Collaboration NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician. SOURCE: AARP, 2010b. Courtesy of AARP. All rights reserved. Exclusive scopes of practice exacerbate interprofessional tensions. Recommendation # 1 Remove Scope of Practice Barriers Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends actions for the following entities: State Legislatures Congress Centers for Medicare and Medicaid Services Office of Personnel Management Federal Trade Commission and Antitrust Division of the Department of Justice Citizen Advocacy Center 2 nd Quarter 2010 Practice All practitioners should practice to the full extent of their education and training Physicians, nurses and other health professionals work in a team-based model of care delivery Models of care maximize time that providers can spend on their respective roles and responsibilities to patients UCSF Center for the Health Professions 6 2/28/2012 Practice Evidence Key Message #2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Studies show that APRNs permitted to practice to full extent of education and training provide equal or better care Systematic review of published literature between 1990 and 2008 indicate patient outcomes of care provided by APRNs and equivalent or better than MD Patient satisfaction Length of stay NPs: BP, glucose, lipid control CNMs: Fewer C-sections, fewer episiotomies To ensure the delivery of safe, patient-centered care across settings, an improved nursing education system is critical. To respond to changing patient needs and an evolving health care system, nurses must achieve higher levels of education and training. Education should include opportunities for seamless transition into higher degree programs. Education Education Increase the proportion of nurses with BSNs to 80 percent by 2020 Evidence Double the number of nurses with doctorates by 2020 Implement nurse residency programs Promote lifelong learning Significant association between educational level and patient outcomes Twenty percent of BSN graduates get advanced degrees Six percent of associate-degree graduates get advanced degrees Key Message #3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. As leaders, nurses must: Act as full partners with other health care professionals Be accountable for their responsibility to deliver highquality care. Work collaboratively with leaders from other health professions. Identify and propose solutions to problems in care environments Devise and implement plans for improvement Participate in health policy decision-making. Collaboration Integrated, collaborative, patient-centered health care teams Prepare more nurses to help lead improvements in health care quality, safety, access and value UCSF Center for the Health Professions 7 2/28/2012 Leadership Evidence Nurses bring important viewpoint to management and policy discussions Interprofessional education, training and practice Gallup survey of 1,500 opinion leaders* said nurses should have more: Influence in reducing medical errors, increasing quality of care, promoting wellness Input and impact in planning, policy development and management Survey of 1,000 U.S. hospitals** found: Nurses account for only 6 percent of board members Physicians account for 20 of board members Other clinicians are 5 percent of board members TCAB: Falls with harm, code blue calls, 30-day readmissions declined 71 percent of floor nurses felt their ideas counted after TCAB, up 13 percent *RWJF, 2010 **American Hospital Association, 2011 Recommendation # 8 Build an infrastructure for the collection and analysis of interprofessional health care workforce data. Data The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible. Research on health care workforce is fragmented Need data on all health professions Improved health care workforce data collection to better assess and project workforce requirements Collecting workforce data at licensing and renewal is most valuable if it s 1.Easy 2.Electronic 3.Evenly applied Keep it Easy: Link short, focused surveys to re-licensure. UCSF Center for the Health Professions 8 2/28/2012 Keep it electronic: Collect and manage the data online. Keep it Evenly Applied: Standard data permit trend and comparison analyses. Campaign for Action State Involvement UCSF Center for the Health Professions 9 2/28/2012 Change drivers, PPACA and IOM Report will create new care practice models New models will push for expanded scopes of practice New models will encourage shift from acute and specialty care to Management of chronic conditions Primary care and care coordination Integration of mental & behavioral health into physical care Prevention and wellness Prevention of adverse events New models will push providers and consumers to rethink how and where care is delivered. Three Take- Away Themes INTEGRATION UCSF Center for the Health Professions 10 2/28/2012 ACCOUNTABILITY CREATIVITY Understanding how the future of nursing fits into current health care context provides tremendous opportunity. Change Drivers PPACA IOM Campaign Resources Visit us on the Web Follow us on twitter Join us on Facebook UCSF Center for the Health Professions 11 2/28/2012 Catherine Dower UCSF Center for the Health Professions (415) Dower UCSF Center for the Health Professions 12 Campaign Update Since its release one year ago, the landmark report from the Institute of Medicine (IOM) The Future of Nursing: Leading Change, Advancing Health has had considerable impact on the U.S. health care system and on how members of the health care workforce approach their work. Similarly, the Future of Nursing: Campaign for Action has made significant progress during its initial work to implement the report s recommendations. Building on the first year of progress since the report release in October 2010, action items for 2012 include the following: Expansion of Action Coalitions to as many of 50 states by early Continuation of the Learning Collaborative on Advancing Education Transformation, established in Four models have been identified and Action Coalition education work teams are exploring which ones will best fit their states and are incorporating them into their plans. Nursing leadership: o Nurses on Boards: Pilots developed in Virginia, Rhode Island and New Jersey are being further developed as models for other states. o National nurse appointments: Working closely with national nursing organizations Implementing tracking mechanism for national board-level appointments Goal is to anticipate vacancies and encourage succession planning o Leadership in nursing practice: Identifying models within practice areas, leading nursing organizations, and doctoral programs that are leading change and advancing health Diversity Steering Committee: Will convene for the first time in early 2012 to create strategic plan to provide diversity-related advice and technical assistance to Action Coalitions. Removing Barriers to Practice and Care: An RN Barriers Steering Committee will identify barriers to utilization of nurses who are not practicing to the full extent of their education and training; develop strategies for reducing these barriers; and engage key stakeholders in implementing the strategies at local, state, and national levels. Several Action Coalitions will participate in a community organizing training to help them develop their strategic and action plans. National Summit: In Fall 2012, the campaign will convene Action Coalitions from as many as 50 states for a national summit. The goal is to educate, engage and energize Action Coalition members in a focused and effective convening so that they return home better equipped to execute campaign activities in new, more impactful ways. AARP will track the Department of Health & Human Services report to the Senate Appropriations Committee on their action plan to respond to the IOM Future of Nursing report. 2011 accomplishments include: Vermont Governor, Peter Shumlin is forming a state Blue Ribbon Commission to work on the recommendations within the Future of Nursing: Leading Change, Advancing Health. AARP Vermont is slated to join the commission. The Leapfrog Group, for the first time, reported a hospital s Magnet status as an indicator of adequate and competent nursing staff service and nursing leadership at all levels on its public 2011 Hospital Survey. The Leapfrog Group cites no other external credentialing or similar entity in its hospital survey. In May, CCNA hosted a national webinar with Ellen Marie Whelan, currently with the Center for Medicare and Medicaid Innovation, on Enhanced Opportunities for Nursing in an Evolving Health Care Arena. In June, CCNA co-hosted with the National Rural Health Association and the Robert Wood Johnson Foundation an AARP Solutions Forum on Advancing Health in Rural America: Maximizing Nursing s Impact. The event was keynoted by HRSA Administrator Mary Wakefield and included panelists from the Veterans Administration, the Indian Health Service and rural health leaders in several states. More than 100 participants attended in person, with an additional 200+ joining via live webcast. In December, with the Convenient Care Association, CCNA hosted an AARP Innovation Roundtable on Transforming Health Care Delivery Convenient Care: Opportunities for the Future. The roundtable included representatives from leading retail clinic operators, such as Target, CVS Minute Clinics, Walgreens (Take Care Health Systems), and Belin FastCare. About the Campaign for Action The Future of Nursing: Campaign for Action envisions a health care system where all Americans have access to high-quality care, with nurses contributing to the full extent of their capabilities. The campaign is coordinated through the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation, and includes 36 state Action Coalitions and a wide range of health care providers, consumer advocates, policy-makers and leaders from the business, academic and philanthropic communities. The Future of Nursing Leading Change, Advancing Health Report Recommendations Advising the nation/improving health For more information visit Report Recommendations 1 Key Messages Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and an improved information infrastructure. Recommendations Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions. For the Congress: Expand the Medicare program to include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered. Amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities. Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services. Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18). For state legislatures: Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18). Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law. 2 The Future of Nursing For the Centers for Medicare and Medicaid Services: Amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff. For the Office of Personnel Management: Require insurers participating in the Federal Employees Health Benefits Program to include coverage of those services of advanced practice registered nurses that are within their scope of practice under applicable state law. For the Federal Trade Commission and the Antitrust Division of the Department of Justice: Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anti
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