Wooden people figured represent nursing in community care

A century ago, nurses were often the sole providers in primary care settings. It was only after World War II that health care became centered around hospitals and education programs preparing nurses to provide inpatient care. Today, nearly 60% of registered nurses (RN) work in hospitals. With the Affordable Care Act (ACA) driving the nation toward better quality and cost-effective care, registered nurses are in a prime position to lead the healthcare establishment toward a focus on wellness and prevention at the primary care provider level.

Factors Driving the Change in Healthcare Models

Health care has become fragmented, poorly accessible, and too expensive to be sustainable in the future. This leads to poor health outcomes for our most vulnerable populations. With the current focus on value-based fee structures instead of costly fee-for-service models, changes are inevitable.

Current trends toward community initiatives center around population health, which focuses on improving the health of groups of people such as senior citizens, school-age children, or people with diabetes. These initiatives are best served in the community setting.

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Even as we move toward more community-based care, primary care providers are retiring at a rate that will exceed the number of providers entering primary care each year. The reverse is true for the nursing profession. The U.S. Bureau of Labor Statistics Occupational Outlook Handbook projects employment of registered nurses to grow 12 percent between 2018 and 2028, attributing the increase to rising rates of chronic conditions and a focus on providing quality preventive care. This will open opportunities for nurse practitioners and nurses to fill important team member roles in primary care practices.

Challenges to the New Model and Possible Solutions

The healthcare system has some hurdles to get over, but healthcare leaders at the June 2016 Josiah Macy Jr Foundation Registered Nurses: Partners in Transforming Primary Care conference proposed several solutions.

  • Nursing education is primarily focused on hospital-based care. If primary care practices are to provide quality care and better outcomes, nursing schools must provide primary care-centered education opportunities and properly trained educators to lead them.
  • The patient care provided by nurses is typically not covered by insurers. Insurers must redesign payment models so that the work done by RNs to meet the goals of the current ACA healthcare model is directly reimbursable.
  • Continuing education focused on primary care is lacking. Current employers of RNs should offer and encourage continuing education in primary care.
  • The role of the RN in primary care is limited. State boards of nursing and primary providers should expand the RN role to include medication management and the use of standing orders in the team-based management of patients with chronic conditions.

New Roles for RNs and Proven Success

Even today, RNs are leaders on the front lines. They assume roles as care managers and health coaches, providing education and advocacy for chronically ill patients. As trusted members of the healthcare team, RNs are well-positioned to work closely with patients and caregivers to develop care plans that consider patient-specific needs and values.

During 2012 and 2013, the Robert Wood Johnson Foundation (RWJF) initiated The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), a project developed to identify and learn from innovative primary care practices. Ed Wagner, MD, MPH, co-director of LEAP, observed the benefits of moving nurses into enhanced roles. He said, "The practices that are engaging nurses in these new, expanded ways are showing better clinical performance and better patient experience[s]."

The Registered Nurses: Partners in Transforming Primary Care conference proceedings note that nurses are in a good position to provide care coordination, engage with patients to promote behavior change, provide medication management according to provider protocols, promote population health in their communities, and take on leadership roles as practices strive to reduce costs and increase benefits for patients.

Mary Naylor, Ph.D., RN, FAAN, national program director for the RWJF-sponsored Interdisciplinary Nursing Quality Research Initiative, reports that nurses will experience a higher level of responsibility in providing transitional care as patients move from hospital to homes, ensuring better continuity of care and improved outcomes.

As members of the local community, nurses can connect at-risk patients with community services. This is especially important for aging patients, patients with chronic conditions, and patients who need additional substance abuse and mental health services that are not provided at the primary care office.

Registered nurses are positioned to become leaders in healthcare as the industry moves toward promoting health and wellness. While nurses will still be found in hospitals, many will engage in learning experiences to prepare them for expanded roles as care coordinators, care managers, nurse educators, and nurse navigators. These nurses will enhance the primary care teams by providing critical wrap-around care that embraces the totality of each patient, meeting the community and their patients where they live.

Janine Kelbach, RNC-OB

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