One of the last meetings I atteded as the AAN/AARP Fellow was held in New York City the end of October. The purpose of the meeting was to identify opportunities and barriers to nurses’ involvement in culture change initiatives in nursing homes, advance the science of culture change, and to draft a White Paper delineating nurses’ role as clinical leaders in culture change.
Download Press Release- Nurses Involvement in Changing the Culture in Nursing Homes
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Finally the nursing shortage has received some well-deserved coverage
that, in many ways, actually did the subject justice. Now with David
Brancacc, a weekly half-hour television show of investigative journalism
on PBS (previously hosted and made famous by Bill Moyers ,has focused its
attention on the nursing shortage in America. I only hope that the message
delivered is heard by the people who most need to hear it.
With a shortage of as many as one million nurses projected by the year
2020, calls to address this crisis within the troubled American
healthcare system are becoming louder and louder.
As described in the course of the program which aired Sunday, Oct 24 on
PBS, nurses are the engine that keep the healthcare system humming.
While doctors may sometimes receive the lions' share of the praise for
life-saving surgical techniques and heroic medical measures, it is
round-the-clock nursing care that can often mean the difference between
life and death. And as outlined during Mr. Brancaccio's investigative
story, a number of studies have demonstrated quite clearly that when the
number of patients cared for by nurses increases, mortality also
increases. And by most measures, successful outcomes most often directly
correspond to the quality of nursing care received.
As the population ages and lives longer with more chronic illness, the
need for nurses in hospitals, health centers, nursing homes, and in home
care will continue to increase exponentially. (It was pointed out during
the broadcast that approximately 75 cents of every healthcare dollar is
spent on chronic illness.) And with nurses working harder as salaries
remain essentially stagnant in the face of increasing workloads and a
sagging economy, attrition from the profession should be of paramount
concern.
Speaking of attrition, approximately 25% of new nurses reportedly leave
the profession each year, and one can only imagine that falling from the
frying pan of nursing school into the fire of full-time nursing may be
one of the many factors that push new graduates right out of the
profession before they have even had the chance to settle in.
As 25% of new nurses leave the profession, the average age of the
American nurse continues to increase, with retirements from active duty
occurring on a daily basis. Meanwhile, 70% of nursing schools turn away
thousands of qualified applicants due to a shortage of nursing faculty
which, if left unchecked, will continue to cripple any efforts to
assuage a shortage that only seems to expand with each year that passes.
An idea for retaining new nurses who have recently entered the field was
explored during the broadcast. Some facilities utilize a year-long
residency or internship structure so that new graduates actually receive
the guidance and mentorship needed to make it in the real world,
post-nursing school. Similar to the medical residency that newly-minted
doctors receive, a nursing residency or internship allows a new nurse
sufficient time to receive the focused training that he or she will need
in order to deliver high quality and safe care. Thus prepared for
full-time nursing, the new graduate is thus less likely to burn out, and
more likely to succeed in his or her work and be satisfied with a newly
chosen profession that desperately needs to retain its newest recruits.
Watch the Now broadcast in streaming video on your computer...
Find out what hospitals in your state have received the American Nurses Association "stamp of approval"...
Follow a week in the life of a new graduate working on a New York City burn unit...
My one criticism of the program is that, like all media covering nursing
and the shortage, only hospital-based nursing was addressed. There was
no mention of home care, community health, public health, psychiatric
mental health nursing or school nursing, areas which are also struggling
mightily with the effects of the shortage. This focus on hospital
nursing-however important hospital care certainly is-only serves to
underscore the public's (and the media's) misconceptions about nursing.
Our society seems to see nurses solely as workers in the hospital,
overlooking the fact that nurses provide crucial care to myriad
populations of citizens well beyond the walls of the nation's hospitals.
Such media attention on the crisis of the national-and global-nursing
shortage is truly needed, and it is only by educating the public (and
our elected officials) about the crucial need for nurses that change and
growth might occur. While Barack Obama and John McCain both have, to
some extent, made gestures vis-a-vis the shortage of nurses in America
today, a new administration in Washington will have many pressing issues
to address as power is assumed in January of 2009, and fixes to the
healthcare system will certainly take time.
No matter how the economic climate evolves, people will still get sick
and need nursing care and medical care. No matter how many banks fail,
hospital doors will still be open, visiting nurse agencies will visit
patients at home, and surgeries and emergencies will continue to occur.
Even as the global economy reels from the latest financial implosion,
qualified applicants will be turned away from nursing schools and
shortages of nursing faculty (due to relatively low salaries and other
factors) will plague the halls of academia.
A new administration will need to have the political will to take some
bold strides vis-a-vis the American healthcare system. The delivery of
care as it pertains to chronic illness will need to be addressed.
Nursing faculty-the key to educating new nurses in preparation for the
workforce-will need to receive improved compensation for their important
work as educators of future nurses. Nursing students from a broad
socioeconomic spectrum will need scholarships and grants to offset the
costs of a community college or university education. And healthcare
facilities will need funds to give new graduates the time and attention
they need for mentorship and preparation for autonomous practice.
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One great reward experienced from my work here at the Public Policy
Institute at AARP is how the media reports on published reports. Media reports
related to our work on Family Caregiving were released recently. Please refer back to my Blog posting of April
30 to recall my role in this effort. I
was pleasantly surprised to see my work acknowledged in the actual report at
top of page 87 under the Chapter on “Discussion and Recommendations”. The Planning Committee continues to meet and
is seeking funding regarding our future plans to implement these
recommendations.
Patient Care Must Be Redefined To Include Family Members; Professionals and Advocates Pledge To Help Educate Family Caregivers
In a first of its kind collaboration, national organizations representing
nurses, social workers, family caregivers and people age 50+ released a report
calling for a re-definition of good patient care to include those family
members and friends who provide ongoing, often daily, care. Family members are
very often not prepared to take on the task of caregiving--especially as many
family caregivers are providing services typically reserved for registered
nurses and doctors.
The
report, “State
of the Science: Professional Partners Supporting Family Caregiving,” is a joint endeavor of the AARP Foundation, the American Journal
of Nursing, the Council on Social Work
Education and its Journal of Social Work Education, the Family Caregiver Alliance, and Rutgers Center for State Health Policy
(New Jersey).
It was released to coincide with a new "Ask Medicare" initiative from the Centers for Medicare and Medicaid Services, of which
AARP is a key supporter. Links to our online caregiving resources will be
included on a new Web site, www.medicare.gov/caregiver,
which will provide accurate and unbiased information to caregivers about
Medicare.
Overview of the Report
The parties to the report pledged to partner with families in new
ways to:
Read More
Selected Report Contents:
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One aspect of the health care system that seems to inspire everyone’s consensus is the need for health care reform. The debate, however, revolves around WHAT to reform. One concept to drive much change that has gained much attention in health policy and political circles is the “medical home”. The concept of medical home means that the care of people with chronic illnesses will result in better care coordination. My major project over the last several months has been to identify what every nurse should know about care coordination. I am nearly finished with a paper describing the role of nurses in care coordination.
Americans are living longer and the number of older adults is rapidly increasing. With increased age comes increased risk for chronic illness. The high and increasing prevalence of multiple chronic conditions poses challenges for our current health care system. The high cost of care associated with treatment for persons with chronic conditions gives rise to questions about the most appropriate models of care for persons with multiple chronic illnesses. People with multiple chronic illnesses have substantially more health provider contacts and are more likely to be hospitalized each year than those with only one chronic condition. Prior attempts to manage costly utilization of services by persons with chronic illness have been unsuccessful with traditional fee for service methods. Mounting pressure for health care reform has resulted in consideration of easy solutions to restrain health costs—including the concept of a “medical home”.
The “medical home” concept grows out of the disease management literature and was introduced in 1967 by American Academy of Pediatrics with the intent to provide care to children with disabilities. In the United States, projects to put this Medical Home concept into practice center on physicians, not nurses. Yet, the medical literature and experience of providers to improve chronic care indicate that nurses are the key to implementing the chronic care model. By nature of our holistic education and role, nurses are in a position to champion the transformation of chronic care.
Care coordination is one of the priorities to transform the health care system (IOM, 2008). Nurses have taken on the central role in care coordination for decades, and are now being recognized as leaders in care coordination. Nursing models that use coordinated care and report outcomes are very helpful in the debate. Examples of nursing models using care coordination with reported outcomes of this practice include that of the Transitional Care model, EverCare model, and outcomes reported in the literature on Advanced Practice Nursing.
Recommendations regarding care coordination follow:
My major paper describing nursing’s role in care coordination will soon be finished. This paper will be a major product that I’ve enjoyed working on during this Fellowship. Pat Ford-Roegner, Executive Director at American Academy of Nursing (AAN), has mentored me in understanding these issues.
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With the health reform discussion in full swing, improving value for the money we spend on health care is an essential part of the debate. Nurses play a prominent role in improving quality. A growing body of research points to the positive impact that nurses have on coordinating care, reducing hospital readmissions, reducing errors, and improving clinical outcomes – all with a potential to reduce costs.
The American Academy of Nursing partnered with the Alliance for Health Reform – a nonprofit group that hosts Capitol Hill briefings – on a recent forum entitled “Innovations in Patient Care: Lessons from the Field.” The panelists for this event included:
* Reed Tuckson, MD, UnitedHealth Group and Raise the Voice Advisory Council member
* Mary Naylor, PhD, RN, FAAN, University of Pennsylvania School of Nursing and AAN Edge Runner
* Audrey Nelson, PhD, RN, FAAN, Veterans Administration and AAN Edge Runner
* Rick Kellerman, MD, the American Academy of Family Physicians.
Over 200 people registered for the event, and the members of the audience were very engaged – with the Q&A section lasting over an hour. Learn more about the briefing through an webcast, podcast or transcript from The Kaiser Network.
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Briefing
On Friday July 11th, 2008, I attended the Briefing on Long-Term Care Reform
hosted by the Engelberg Center for Health Care Reform at Brookings in
collaboration with The New School and the Center for Health
Transformation.
This event provided an opportunity to identify some of the big challenges in
long-term care quality and financing and also to highlight innovative ideas
and solutions moving forward. Bob Kerrey and Newt Gingrich were featured speakers.
Susan Reinhard, PhD, FAAN (Senior Vice President, AARP Public Policy Institute)
was also featured.
During her talk she focused on the recently released AARP Public Policy Report
summarized below. I think Susan was the best of all the speakers. She
focused on how nurses must be care coordinators and disease managers.
Barriers must be removed to allow nurses to practice in their full scope
of practice. Do take time to review Susan's concrete recommendations on
how to improve our long term care system.
A Webcast of the event is now available online. The Engelberg Center will
welcome any feedback you may have.
Forums on Health Care Reform
Lately I have been attending several Forums on Health Care Reform. Long
term care (LTC) is an important part of discussions on health care
reform. Currently, most LTC dollars are spent on the most expensive
type of care in nursing homes. In the future, states will need to use
their LTC dollars much more efficiently.
The AARP report is a good illustration of the work the AARP Public Policy
Institute is doing in the area of long term care reform. Findings of this survey
across all the states indicated that states are doing much better in
using home and community based services for people with developmental
disabilities and mental retardation than they are for older adults.
Public policy will need to change at the state level to decrease use of
the most expensive types of institutionalization (nursing homes) to that
of making home and community based choices available to older adults.
States that have made the most progress have used case management across
all settings so that patient and caregiver see a nurse to consider all
the available options of care.
The nurse works closely with the patient and family to coordinate care and
makes home and community based care choices available before nursing home
is considered. States that have made the most progress in LTC reform allow
Advanced Practice Nurses to practice at their fullest scope of practice. Incentives such as
monetary rewards will need to be provided to those states that make changes in using their
LTC dollars more wisely. See the press release below for more information about LTC reform.
Press Release
New AARP Report Finds Older Americans Have Limited Access
to Home and Community-Based Services under Medicaid
July 11, 2008
A new report by AARP's Public Policy Institute finds promising signs and
mixed results among state government efforts to balance long-term care
(LTC) options under Medicaid. Unfortunately, according to the report,
only four states spent more than 50 percent of their Medicaid LTC
dollars for older people providing home and community based services
(HCBS). The remainder of the states continues to spend the majority of
their Medicaid LTC dollars for older people on institutional care, such
as nursing homes.
The report, A Balancing Act: State Long-Term Care Reform, is the first
to examine Medicaid spending on long-term care for older people and
adults with physical disabilities, separate from other LTC users such as
people with mental retardation/developmental disabilities (MR/DD).
Nationally, 75 percent of Medicaid LTC spending for older people and
adults with physical disabilities pays for institutional care in nursing
homes. In contrast, states have done a much better job balancing
Medicaid LTC for people with MR/DD, spending just 39 percent on
institutional care. The majority of funds now supports people in home
and community-based settings.
"What states have accomplished for people with mental
retardation/developmental disabilities is remarkable," said Susan
Reinhard, Senior Vice President AARP Public Policy Institute. "It proves
that balancing long-term care is achievable and should be used as a
model to help states provide home and community based services for older
adults."
Medicaid's bias remains a major barrier to leveling the playing field
between options for institutional care and HCBS for older adults,
according to the report. Medicaid is required to provide nursing home
care for older adults who are impoverished and require care, but is not
required to provide HCBS.
"This is backwards. People are entitled to costly nursing home care, but
not to often more cost- effective services in their homes. Clearly home
and community-based services are preferred by older residents," said
Reinhard. "Our research shows that older people want to remain in their
homes as they age. They want independence, choice and control over every
day decisions. However, public funds continue to steer older people into
institutions."
Also highlighted in the report are best practices from states that are
making progress balancing LTC options. Alaska, Oregon, Washington and
New Mexico spent more than 50 percent of their Medicaid LTC budget for
older people and adults with physical disabilities in 2006 on HCBS.
These states embraced a philosophy of delivering services in a way that
allowed older people the greatest independence. The ability of some
states to accomplish substantial reforms for older people and adults
with physical disabilities - as well as increased HCBS options for MR/DD
- demonstrates that obstacles to balancing LTC options can be overcome.
The report examines Medicaid LTC funding because it is the primary payer
for LTC in the country. It found that balancing Medicaid LTC options
will require a commitment from state officials and cooperation from
federal authorities. HCBS can be both cost-effective and responsive to
the preferences of older people and adults with disabilities.
"This underscores the need for better government and private sector
financing options for long-term care. Americans have few options to plan
and pay for their long-term care. Medicare provides only modest funding
for a limited number of services and Medicaid's stringent financial
eligibility criteria require most people to become impoverished to
qualify. It is clear that we must eliminate Medicaid's persistent bias
towards costly and undesired institutional care, and we need to advocate
for more affordable long-term care financing options. Government,
individuals and the private sector all have a role to play," said
Reinhard.
Click here for the new report.
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The press release below issued Thursday, June 26th, 2008 explains how many groups are working together to find solutions to the nursing faculty shortage.
AARP, RWJF, LABOR DEPARTMENT SEEK SOLUTIONS
TO NURSING AND NURSE FACULTY SHORTAGE
WASHINGTON– AARP, the Robert Wood Johnson Foundation (RWJF), and the U.S. Department of Labor (DOL) today are convening a summit of multi-stakeholder groups to identify solutions to the nurse faculty shortage that is forcing nursing schools to turn away thousands of qualified nursing candidates each year. Summit participants will identify and develop approaches to improving nursing education capacity – with the ultimate goal of reversing the persistent nursing shortage that could leave the United States without enough nurses.
“AARP recognizes the important role that states play; they are where the rubber meets the road in terms of health care delivery,” said Senior Vice President of the AARP Public Policy Institute and Chief Strategist for the Center to Champion Nursing in America Susan Reinhard. The Center to Champion Nursing in America is a joint initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation. “Nurses play a significant role in reducing medical errors and improving health care quality, which is why we urgently need to find solutions to address both the shortage of nurses and the shortage of faculty to educate them,” Reinhard added.
The summit comes at a critical time for nursing. Latest surveys project that the United States could fall short by close to half a million registered nurses by 2025 absent aggressive action. Currently, the supply of new nurses is failing to keep pace with rising patient demand, in part because a significant number of interested and qualified nursing school applicants have been turned away in recent years due to a growing shortage of nursing faculty.
“The time to simply talk about the problem is over,” said RWJF Senior Program Officer Susan Hassmiller. “What’s essential now is to fundamentally rethink how nurses are and should be educated and how they should be deployed in the workforce. The experiences of these states offer the best hope for achieving these goals.”
A white paper–“Blowing
Open the Bottleneck: Designing New Approaches to Increase Nurse Education
Capacity” –will be released at the summit. The paper highlights programs that are making progress in addressing
both shortage and education capacity problems in nursing. The white paper and
information about the June 26-27 summit can be found at the Center to Champion
Nursing in America website: www.championnursing.org, and at the Department of Labor website: http://workforce3one.org/nursingsummit/.
The AARP Foundation is AARP’s
affiliated charity. Foundation programs provide security, protection and
empowerment for older persons in need. Low-income older workers receive the job
training and placement they need to re-join the workforce. Free tax preparation
is provided for low- and moderate-income individuals, with special attention to
those 60 and older. The Foundation’s litigation staff protects the legal rights
of older Americans in critical health, long-term care, and consumer and
employment situations. Additional programs provide information, education and
services to ensure that people over 50 lead lives of independence, dignity and
purpose. Foundation programs are funded by grants, tax-deductible contributions
and AARP. For more information visit www.aarp.org/foundation.
AARP is a nonprofit, nonpartisan membership organization that helps people 50+ have independence, choice and control in ways that are beneficial and affordable to them and society as a whole. AARP does not endorse candidates for public office or make contributions to either political campaigns or candidates. We produce AARP The Magazine, the definitive voice for 50+ Americans and the world's largest-circulation magazine with over 33 million readers; AARP Bulletin, the go-to news source for AARP's 39 million members and Americans 50+; AARP Segunda Juventud, the only bilingual U.S. publication dedicated exclusively to the 50+ Hispanic community; and our website, AARP.org.
The
Robert Wood Johnson Foundation focuses on the pressing health and health care
issues facing our country. As the nation's largest philanthropy devoted
exclusively to improving the health and health care of all Americans, the
Foundation works with a diverse group of organizations and individuals to
identify solutions and achieve comprehensive, meaningful and timely
change. For more than 35 years the
Foundation has brought experience, commitment, and a rigorous, balanced
approach to the problems that affect the health and health care of those it
serves. When it comes to helping Americans lead healthier lives and get the
care they need, the Foundation expects to make a difference in your lifetime.
For more information, visit www.rwjf.org.
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Preparing for the National Nursing Education Summit
During these Spring 2008 months I have been active along with
a Team of Advisors to prepare for an upcoming event that addresses the critical
issue of expanding nursing education capacity. Nationwide, many college and
university nursing programs do not have the physical space, faculty, clinical
resources, or funds to enroll and educate the numbers of students needed to
meet future nursing demands. In 2006, the National League for Nursing reported
that as many as 88,000 qualified applicants to all (community colleges and
university) nursing programs were turned away due to insufficient educational
capacity.
The first day of the meeting will be devoted to an engaging discussion of four key aspects of increasing nursing education capacity: 1) Strategic Partnerships and Resource Alignment; 2) The Role of Policy and Regulation; 3) Increasing Faculty Capacity and Diversity; and 4) Education Redesign. On the second day, teams will gather individually to discuss what they learned and develop action plans. Of 44 state teams that applied to participate in the Summit, 18 teams have been invited to come. Teams will benefit from the experience of their peers and the perspectives of experts in the field.
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The Purpose of the Symposium
Much activity this Spring 2008 has focused on planning and organizing a State of the Science Symposium on Family Caregiving. The Symposium was designed for Professionals in Social Work and Nursing and was held on January 29 and 30, 2008 in Washington,DC.
The purposes of this Caregiving Symposium was to: evaluate the State of the Science on best practices for supporting family caregivers; identify factors that influence nurses’ and social workers’ abilities to implement best practices; and develop an agenda for developing additional evidence-based practices and support models. The symposium was conceptualized by Dr. Susan Reinhard as a partnership with many other agencies.
Reinhard served as co-director (along with Diana Mason, Editor, American Journal of Nursing) of a symposium entitled “State of the Science: Nurses and Social Workers Supporting FamilyCaregivers”—a collaborative project with the AARP Foundation—that sponsored the conference in partnership with the Family Caregiver Alliance (FCA), the Council on Social Work Education (CSWE), the Administration on Aging Family Caregiver Support Program, Rutgers University Institute for Health Policy, and the American Academy of Nursing (AAN). You will note that most AARP work is done thru partnerships. This symposium is another example of partnerships formed between stakeholder organizations interested in family caregiving.
My Role in the Symposium
My participation consisted of serving on a Steering Committee to plan the symposium. All such events take many hours of meeting in person and also having conference calls to make sure Symposium goes smoothly. During the Symposium I was chosen to facilitate one of the discussion groups.
The outcome from these discussion groups was to identify competencies and strategies to enhance support for family caregivers and also to identify research priorities. I was responsible for summarizing the Research Priorities which became one outcome from our group work at the Symposium. The Research Priorities will become part of the final report.
The Symposium final report will be widely disseminated, including being published as a special supplement to the American Journal of Nursing, in September 2008, and also as a special supplement to the Journal of Social Work Education. The Advisory Committee is still hard at work formalizing the following final documents: 1. Knowledge and Competencies needed by nurses and social workers to support family caregivers; 2. Recommendations for Developing Nurse and Social Worker Competencies to support Family Caregiving; 3. Primary Recommendations; 4. Recommendations for Strategies to Increase the Ability of Nurses and Social Workers to Support Family Caregivers and lastly 5. A Proposed Agenda for Research on Family Caregiving.
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Earlier this month it was wonderful to welcome
Valerie McCarthy to AARP and the Center to Champion Nursing in America (CCNA). Valerie
was given an office and email access during the 2 weeks she was with us March 2-14, 2008.
Valerie is a doctoral student at University of Louisville
School of Nursing in
Louisville, Kentucky. Her special area
of interest is in the health and wellness of older adults. She is here
doing her Social Policy Practicum related to understanding Issues in
Aging. Valerie is a resident of beautiful southern
During Valerie’s second week we attended the Public Policy
Institute of American College
of Nurse Practitioners. This invitation came about because I
represented Dr. Susan Reinhard in a presentation about AARP’s CCNA. Download thank_you_letter.doc
Attendance allowed us to talk frequently at
lunch about the importance of doing an Op Ed on the importance of Nurse
Practitioners in Primary Care.
Valerie's Op Ed
The most important outcome
Valerie produced was an Op Ed in response to the reauthorization of
health professions education programs established under Title VII of the Public
Health Service Act (PHS).
The background information for
this idea about Op Ed started from Pat Ford-Roegner
I thought that American College Nurse Practitioners (ACNP)
would be a wonderful vehicle to author the idea of identifying strengths of
nurse practitioners as part of multidisciplinary team. Then, Nancy Sharp (Senior
Health Policy Expert for ACNP) found the editorial below in USA Today:
USA Today March 13th, 2008 Article
It gave us an excellent opportunity to respond. Valerie and
I attended the Advanced Public Policy Institute with Nancy Sharp. We talked
several times with Nancy Sharp about doing an Op Ed. The Op Ed needed to get
out quickly in response to the USA Today editorial. Nancy was able to get approval from her Board
quickly. In summary, a special huge thank you goes to Valerie for
taking this on as her project and production of this wonderful Op ED.
March 27, 2008
An Op Ed was submitted for publication in USA Today. They informed us that it was too long for them to publish. They requested it be downsized to a 250 word editorial. ACNP downsized and resubmitted as an editorial on the same day. Please find the link below to the editorial:
USA Today March 27. 2008 Op Ed Article
Thanks again to Valerie!
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