Soon the nation will have to face the reality that our system of health care, evolved over the past fifty years, is financially and clinically unsustainable. After the financing discussion has progressed and the silos of service that cost so much and underperform so often have begun to re-integrate, then the public will begin to look for new ways to consume health care.
It seems unlikely that we will have a single system or even different varieties of a single “best” approach to service. The reasons for this are complex, but include our culture of freedom, where choice and individual decision making are so highly valued, and where the boogey man of socialism is frequently invoked to block any rational attempts of policy change. Detractors of publicly funded health care will rarely point out that few of those in the Medicare program would give up their coverage, just because it is being run by a “governmental bureaucracy.” As a nation, we have a great variety of needs that can be segmented by age, geography, income, education and condition of health. Moreover, we remain a country that is greatly stratified by wealth. While this may not be the best for us in the long term, it remains a fact and does not seem likely to change in the near future. Those who have greater access to resources may choose to buy a set of health care services that they perceive are better or more responsive to their needs.
The forms that new practice models will take will increasingly be dependent on consumer choice, but it will be consumer choice that is mediated by criteria of affordability and efficacy. It will be increasingly more difficult to achieve these criteria, if we manage only to shave a few dollars off of the cost of a hospital stay or re-position the ambulatory practice to be more patient orientated. Such efforts are not likely to produce changes in savings or other outcomes that are substantial enough to make a material difference in our system of care.
To achieve substantial changes, the nation will need entrepreneurial efforts that substantially disrupt the status quo of how we organize the delivery of services. To build such new approaches it will be wise to begin with programs that grow out of efforts that we know already work and which might be expanded or modified. One underutilized health care resource is the nation’s nurses. At well over three million in practice, registered nurses represent the largest and most widely spread of all health care professionals. Their skills match up well with what the nation will increasingly need in its delivery system. For instance, there are very few who look to the future of health care that do not see an environment where the system must develop new ways of managing care for patients who have a chronic disease or disability. The core skill set of every nurse includes competencies which enable them to understand and manage patient care across a wide variety of environments, from the hospital room to the ambulatory facility to the home. Moreover, the generalist approach to care services means that nurses typically bring the capacity to manage and integrate care for patients with complex needs.
There are many ways to identify opportunities for innovation in the delivery of health care services. A few of them merit special attention as the reform effort moves to remaking the practice models that drive the costs and effectiveness of our health care investment.
Community Clinics – Community clinics deliver care to about 15% of the nation and many of these clinics are run by nurses, who also provide a great deal of the care to the patients of the clinic. In part because these clinics often lack some of the traditional resources, they focus on case management, prevention, chronic care management, culturally responsive care, and community engagement. They have become sources of innovation for the broader health care system. Their form of community based, consumer responsive and cost effective care could become a part of the looming shortage of primary care resources. To do so they will need the encouragement of public oversight agencies, imaginative leadership, and a new brand image with the general public.
School Clinics – Once an essential part of the nation’s delivery system as it addressed communicable diseases, in many districts these clinics have lost have lost ground as school budgets have been cut. Still, over 50,000 nurses across the nation provide
community-based prevention, education and treatment resources to uninsured, low-income and homeless children. In many locations where school nurse programs remain vibrant, these health professionals are the providers of essential daily services to children with complex care needs. Only 12 states comply with the federal guidelines of one RN for every 750 students. But as the nation makes the transition from a treatment orientation to one of prevention and management, the schools offer a cost effective way to provide a wide set of services to uninsured, low-income, and even insured students across the economic spectrum.
Ambulatory Chronic Care Management – One of the most expensive components of the current US health care system is the acute care system. This is because it is misused to manage the delivery of care of the growing population with chronic health needs. Every time the emergency department, ICU, or Med-surgery unit is used to provide care for a patient that could have remained in the community with more active case management, hundreds of thousands of dollars are wasted. The traditional primary care delivery system is not structured to deliver the intensive, high contact services that characterize best practices for chronic care. Many new delivery structures, ones that are developed from and based in nursing care models, have demonstrated that they can manage chronic care less expensively and achieve similar or better outcomes. Moving to these models will require new methods of payment, aligned and integrated systems of care, and innovation by nursing leadership.
End of Life Care – The underutilization of palliative care services at the end of life is one of the most costly and inhumane aberrations in American health care. Some estimates conclude that hospice is used in less than one in five cases in which it is indicated. Nurses are trained in psycho-social-behavioral care. In their role as the communicator between physicians, patients and family in a variety of care settings, they represent an untapped resource for the repositioning of palliative care in our system Advancing this agenda will likely require a more aggressive educational program and a willingness for nurse practitioners to become more entrepreneurial in their approach to their work.
Maternity Care – At the other end of life, nurse midwifery represents one of greatest underutilized resources in our health care system. In most European nations, uncomplicated deliveries are assisted by nurses with favorable outcomes in quality, costs and satisfaction when compared to the US. These services represent an important income stream for most of the nation’s hospitals, but it is very important to look at how this dominant practice model might be reorganized around a nursing model in order to create a more responsive system. While these services are likely to be delivered in birthing centers, they will nonetheless need leadership from the professional ranks of nurses.
These and other new practice models for nurses will not come about because the existing system invites the profession in. Rather, the profession must be willing and able to take their current level of success in each of these domains and enlarge their impact to new arenas and locations. These nurse leaders will also need to bring creativity and the capacity for developing new partnerships. Finally nurses will need to give up some of their traditional patterns of practice and expectations to achieve these necessary leadership roles.