New Care Delivery Models Expanding RN Opportunities

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By Debra Wood, RN, contributor 

March 21, 2013 - As the health care landscape changes and new care delivery models such as accountable care organizations and medical homes become more common, greater career possibilities and new nursing jobs will open up--especially for nurses skilled in care coordination, data analysis and improving patient outcomes.

Patty Jones sees plenty of work for all nurses
Patty Jones, RN, MNA, indicated plenty of work exists for all nurses.

“Accountable care and a lot of the initiatives coming out of health reform provide some interesting and new opportunities for nurses,” said Patty Jones, RN, MNA, a principal at Milliman, a consulting and actuarial firm in Seattle, adding that the positions will take advantage of skills nurses already have and necessitate some to develop new talents.

Suzanne Wells, MSN, RN, president of the American Academy of Ambulatory Care Nursing in St. Louis, called it an exciting time for nursing.

“The momentum will do nothing but accelerate,” Wells said. “Nurses have a responsibility to exercise their voice to assure they have the opportunity to play key roles in the transition to ACOs and medical homes. No one is going to advocate for us.”

Accountable care organizations  

Accountable care organizations (ACOs) assume responsibility for a population of patients. Those participating in the Medicare Shared Savings Program will split any savings associated with better management of care with the government.

“For an accountable care organization to be successful, they are tasked with coordinating the needs of a member or a patient over a series of services and different levels of care over the course of time,” said Jones, explaining that efforts will focus on case managing smoother transitions between settings and ensuring the patient takes prescribed medications and follows through with appointments to avoid rehospitalizations. 

“This is a natural place for nursing and nurse leaders to use skills in terms of care coordination and assist the patient to reach out and get attached to other levels of care,” Jones said.

Newer emerging roles, Jones said, involve patient education and engagement. But the teaching must take place within the framework of the patient’s readiness to learn and motivation for changing to a healthier state.

“It’s a coming together of the science and psychology of nursing,” Jones said.

A third area of opportunity for nurses involves resource management at the patient and organization level, not something all nurses are skilled at or interested in.

“There are real opportunities for clinical leaders, nurses included, to be part of the financial and resource management discussion,” Jones said.

Additionally, nurses will need a population view, similar to a public health approach, to identifying and closing gaps in preventive care. However, it will require an analytic mind and comfort with data.

Patient-centered medical homes  

Mary Ellen Roberts: RN skills contribute to medical homes
Mary Ellen Roberts, DNP, RN, APNC, FAANP, FAAN, said nurses have the skills to successfully contribute to medical homes.

Patient-centered medical homes (PCMHs) emphasize care coordination and communication, which can lead to higher quality and lower costs.

“Nurses will take the medical home model and bring it to the forefront,” said Mary Ellen Roberts, DNP, RN, APN,C, FAANP, FAAN, director of the doctor of nursing practice program at Seton Hall University College of Nursing in South Orange, N.J., which has incorporated into its curriculum information about the new models.

“Nurses have the skills already,” Roberts said. “They are taught to be patient advocates … and they have the skill to teach patients about their conditions.”

Carol Murtaugh, RN, administrator for Hematology and Oncology Consultants in Omaha, Neb., an oncology-focused medical home, called nurses “key to making sure all of the pieces come together” across specialties while managing the disease, side effects and addressing psychosocial needs and adherence issues.

Carol Murtaugh: Nurses' care coordination key in medical homes
Carol Murtaugh, RN, said nurses play a key role in bringing the pieces together across specialties in the medical home model.

“We will see nurses grow in the role as care coordinators and navigators,” Murtaugh said. She also expects nurse will play a larger role in process improvement and in ensuring practices adhere to treatment guidelines to promote quality, value and expected outcomes.

“Data management and data analysis will become part of the nursing role,” Murtaugh predicted. “Phone triage will become key.” She explained that a nurse taking the call can help avoid costly emergency department visits.

Wells also sees opportunities for nurses with “first-call” resolution of patient problems--as well as more telehealth as technology advances and greater use of nursing call-center positions--as practices delegate some of the patient teaching, follow-up, triage and other matters to nurses skilled at telephonically managing care. 

Parkland Health and Hospital System in Dallas recently added new programs to its medical homes. Nurses follow up with patients by phone during “virtual encounters” to provide education and support for lifestyle modifications, as well as discuss how patients are doing toward achieving their goals and managing their chronic conditions.

Kay Lynn Frank: New nursing jobs take a global approach to health care
Kay Lynn Frank, RN, expects nurses will engage in a more global approach to health care management.

Nurses also teach patients during shared visits, another new model, which allows patients to ask questions and receive support from fellow patients, said Kay Lynn Frank, RN, director of nursing for Parkland’s community-oriented primary care clinics.

“Nurses are going to become more involved in population management,” Frank said.  “Registered nurses will be able to identify barriers for patients with chronic diseases and help them develop goals and behaviors that will meet their needs in a community. We’re looking at a more global approach to health care management.”

The growth of Medicaid  

With the growth of Medicaid, a key component of the Affordable Care Act, more patients with social needs as well as medical needs will enjoy access to the health care system and referrals to community-based services.

“This is the rebirth of visiting nurse and community-based nursing,” Jones said. “There’s a real opportunity for nurses to be innovators in optimizing the use of those resources.”

That might include home telemonitoring and other high-tech services.

Additionally, Medicaid managed care programs are expanding delivery models. The point-of-care case management program at EmblemHealth in New York embeds nurses and other team members in medical offices to follow up with patients discharged from the hospital. And EmblemHealth started a Neighborhood Care program, placing nurses and other staff members in storefronts to help members navigate the system and solve problems.

Preparing for the future 

Erica Martinez: RNs have new opportunities in care delivery models
Erica Martinez, RN, MSN, CNE, said nurses must be open to new opportunities and interesting challenges.

Malcolm X College in Chicago is preparing students for careers in the ambulatory and long-term care settings and informing them about the new delivery models and the skills they will need to succeed, said Erica Martinez, RN, MSN, CNE, program director for nursing at the college.  

“We tell them they are expected to be life-long learners,” Martinez said. “Health care keeps changing, and they must be aware that their careers will be different over time. A lot of it is learning to be change agents and adaptable.”

While many experienced nurses already possess the skills to slide into care coordination and leadership positions in new care models, Jones suggested more should be done to prepare other nurses for these new nursing jobs. That might include training in team leadership, change management, financial skills, analytics, operations management and building new initiatives.

Wells also sees the need for nurses with skills in data analysis process improvement methodology and strategic visioning, and for those skilled in health care technology.

Jones indicated plenty of work exists for everyone, and nurses should conduct a self-assessment of their comfort levels with change, finances, data and management of resources before jumping into new delivery models.

“ACOs and a lot of health care reform is dependent on trying new designs and processes, some of which won’t work,” Jones said. “Nurses must have the ability to be flexible and reinvent and be comfortable with change.”


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