ONE of my patients called me with a high fever, chills and dropping blood pressure. He was 48 and had been a quadriplegic since he was shot during a robbery in the hardware store he owned. I called an ambulance and admitted him to the hospital, where we soon brought his urinary tract infection under control. But he developed a bedsore, which became infected with an antibiotic-resistant bacterium that breeds in hospitals. He didn’t survive the hospitalization.

This was in 1998. Ever since, I have struggled to treat my patients in their homes and avoid hospitals except when absolutely necessary. I practice general internal medicine on Roosevelt Island in New York City’s East River, where many of my patients are elderly and homebound: survivors of the polio epidemic, people with multiple sclerosis, paraplegics, some on respirators.

Patients who are treated at home by a doctor and nursing staff who know them intimately and can be available 24/7 are happier and healthier. This kind of care decreases the infections, mistakes and delirium, which, especially among the elderly, are the attendants of hospital care. And it is far more efficient. According to a 2002 study, for the patients treated by the Veterans Affairs’ Home Based Primary Care program, the number of days spent in hospitals and nursing homes was cut by 62 percent and 88 percent, respectively, and total health care costs dropped 24 percent.

I had one 83-year-old patient whose arthritis kept her from moving around, but she loved to talk about her career as a rocket scientist — working on weather rockets, not military ones. One day, a well-intentioned neighbor dropped by and called 911 after finding her feverish and dehydrated from diarrhea.

My patient had never been treated before at the hospital she was taken to, and as a Russian immigrant, had no family here for the hospital to contact. She became disoriented; the hospital assumed she was demented and transferred her to a nursing home. It took me two months to track her down and many more to get her home, where, among well-known attendants and friends, she became lucid again. If she had lived out her days in an institution, she would have cost Medicare a great deal of money, and her life would have been shorter and far less happy.

All too often, ambulances take people to the nearest hospital, not to the one where their doctor is on staff. State laws make it difficult to administer simple treatments in the home. Emergency rooms want to admit patients, and hospitals want to discharge them to nursing homes, rather than send them home.

The good news is that last year’s health care reform act included provisions for the creation of Independence at Home Organizations — groups of doctors and nurses who treat patients in their homes — and incentives to make that work appealing. The organizations can invest in extra services and home visits (for which Medicare typically will not reimburse them) because they will share in a cut of the savings that result from avoiding hospital visits and expensive procedures. The program is to go into effect no later than Jan. 1.

However, Medicare is behind schedule and has not yet issued the rules or applications to begin the process. It has been focusing instead on another provision of the new law intended to deliver more efficient care, creating accountable care organizations — groups of hospitals, doctors and nurses who work together to treat patients. But Medicare should make getting the Independence at Home Organizations up and running a priority.

We have the technology. Electronic medical records can give a doctor with an iPad as much information as any institution. With hand-held machines and a few drops of blood, doctors can get test results in seconds at a patient’s bedside. Portable X-ray and ultrasound equipment can be wheeled into homes. Monitors can alert doctors to any change in a patient’s heart rate.

The fact that this care is possible at home means that the role of hospitals must change. Acutely ill patients who need operating rooms or intensive care will still be brought to hospitals. But they should be quickly discharged to the care of the doctors and nurses who know them best.

For too long the institutions that make up our health care system — hospitals, insurers and drug companies — have told us that “more is better”: more medicines, more specialists, more tests. To rein in spending and deliver better care, we must recognize that the primary mission of many an institution is its own survival and growth. We can’t rely on institutions to shrink themselves. We need to give that job to patients and their doctors, and move health care into the home, where it is safer and more effective.

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While the United States faces some unique challenges in the delivery of health care, it shares many others with countries around the world. An aging population creates demand for more health care services. More people of all ages are living with chronic diseases, with nearly half of Americans affected by diabetes, hypertension, arthritis, cardiovascular disease, and mental health conditions.

As AARP’s 2009 report on chronic conditions¹ details, patients and their family caregivers experience firsthand the lack of care coordination among providers, often resulting in repeat tests and procedures, unnecessary rehospitalizations, and difficult transitions from hospitals to home. And the shortage of nurses and other health care professionals is already acute, particularly in rural and low-income areas. The shortages are expected to worsen as the current workforce retires and the demand for health care grows.

Addressing these challenges requires a transformation of the workforce. It is not just a matter of having more clinicians. We need health care professionals who are better prepared to care for people with multiple chronic conditions in all settings. And we need all of them to be able to deliver care to the fullest extent of their education and training. By virtue of their numbers as the largest health care profession, their scientific knowledge, and their adaptive capacity, nurses must help lead the changes in health care the population needs. To do so, nurses need to assume enhanced and reconceptualized roles in health coaching, chronic disease management, transitional care, prevention activities, and quality improvement.

These are some of the conclusions of the Institute of Medicine’s (IOM) report on The Future of Nursing: Leading Change, Advancing Health, released in October 2010. In partnership with the Robert Wood Johnson Foundation (RWJF), this nonpartisan report is the work of 18 experts in nursing, medicine, economics, business, hospital administration, health policy, consumer issues, workforce policy, and health plan administration. Based on evidence from an extensive review of the research, the report outlines a blueprint for transforming the nursing profession to enhance the quality and value of US health care in ways that meet the future needs of diverse populations. In launching the initiative, RWJF’s president, Dr. Risa Lavizzo-Mourey, noted that “nursing is at the heart of patient care” and is therefore crucial to changing the way health care is delivered so that “patients receive better care at a cost we can afford.” Echoing this sentiment, IOM President Dr. Harvey Fineberg noted that “Nurses are a linchpin for health reform and will be vital to implementing systemic changes in the delivery of care.”

One of the most viewed online reports in the IOM’s history, this landmark report calls on the nation’s leaders and stakeholders to act on its recommendations, including changes in public and institutional policies at the federal, state, and local levels. To spur this action, RWJF has partnered with AARP on the Future of Nursing: Campaign for Action. The campaign’s vision is for all Americans to have access to high-quality, patient- and family-centered care in a health care system where nurses contribute as essential partners in achieving success.

Coordinated through the Center to Champion Nursing in America at AARP, the campaign includes 36 state Action Coalitions (soon to be 45 or more states) and a wide range of health care providers, consumer advocates, policy makers, and the business, academic, and philanthropic communities at the local, state, and national levels. It is focused on three key pillars for change:

1. Advancing Education Transformation
2. Removing Barriers to Practice and Care
3. Nursing Leadership

Interprofessional collaboration and diversity are threads woven through each pillar, with better workforce data forming the foundation of the work.

Advancing Education Transformation

The IOM report emphasizes that if nurses are to be as effective as possible in helping to provide high-quality patient- and family-centered care, they will need to be better prepared as care becomes more complex and moves into the community. We need more nurses with advanced degrees to provide primary care and teach the next generation of students. The report also recommends continuing education to help nurses retain clinical skills and develop leadership abilities. Studies² support a significant association between educational level and patient outcomes, including mortality rates, in acute care settings.

Removing Barriers to Practice and Care

For both immediate and long-term needs, we must enable all registered professional nurses, as well as other health professionals, to practice to the full level of their education and training. In many cases, advanced practice registered nurses (APRNs), such as nurse practitioners and midwives, can be used to address the primary care shortage and free physicians to care for more complex cases requiring their expertise. A 2010 Organisation for Economic Co-operation and Development Health Working Paper³ reports that many countries are searching for ways to improve health care delivery by reviewing the roles of health care professionals, including nurses. The report concludes that developing new and more advanced roles for nurses could improve access to care and might also help contain costs.

The evidence overwhelmingly demonstrates equivalent patient outcomes when care is provided by an APRN or a physician. These studies include several systematic reviews⁴, a randomized, controlled clinical trial published in the Journal of the American Medical Association⁵, and an Office of Technology Assessment publication⁶. Yet, many states have outdated regulations and barriers that prevent nurses from practicing to the full extent of their education and training. For example, nurse practitioners in Arizona can see patients or
prescribe medicine without a physician’s supervision, while their counterparts in neighboring California and Nevada cannot.

Nursing Leadership

Nurses bring an important voice and point of view to management and policy discussions. We need to prepare more nurses to help lead improvements in health care quality, safety, access, and value. A recent survey of 1,000 hospitals in the United States by the American Hospital Association found that nurses account for only 6 percent of hospital board members. Physicians account for 20 percent of hospital board members, and other clinicians make up about 5 percent. Nurses need to see themselves as decision-makers and be able to influence health outcomes. The campaign is fostering appointments of well-prepared nurses to public policy and health care organization boards at the state and national levels. To better prepare themselves for these roles, nurses can find a helpful resource, Nurse Leaders in the Boardroom—The Skills You Need to Be Successful on a Board, at www.championnursing.org.

Leadership needs to happen at every level. One program that has been successful at engaging staff nursing is Transforming Care at the Bedside,⁷ which empowers floor nurses to suggest changes that they think will improve patient care. The changes are tested over a short period, and they are adopted if they prove beneficial. This program has improved patient outcomes, including reduction in falls with harm and 30-day hospital readmission rates.

Interprofessional Collaboration

Interprofessional collaboration stretches across all three campaign pillars. Studies have demonstrated how effective coordination and communication among health professionals can enhance the quality and safety of patient care. Health professionals working collaboratively as integrated teams draw on individual and collective skills and experience across disciplines. They seek input and respect the contributions of everyone involved. That allows each person to practice at a higher level. The result is inevitably better patient outcomes, including higher levels of patient satisfaction.

Data

The campaign seeks to improve health care workforce data collection to better assess and project workforce requirements. Research on the health care workforce is fragmented, and data should be able to reveal the supply of and demand for a combination of health care professionals in a region, instead of single professions.

Diversity

Finally, this campaign aims to diversify the health care workforce. Approximately 33 percent of the US population is part of a racial or ethnic minority group, yet only 18 percent of our nursing students are minorities. By 2050, African Americans, Asians, Latinos, and American Indians/Alaskan Natives will comprise a majority of our population. We need to make sure the nursing profession reflects the patients it serves, and that all nurses deliver culturally competent care.

From Report to Action

International interest in the future of nursing is evident. A few months before the IOM released its report, the United Kingdom released the Front Line Care: the Future of Nursing and Midwifery in England,⁸ prepared by Prime Minister Gordon Brown’s Commission on the Future of Nursing and Midwifery in England. Implementing the commission’s recommendations requires investment and commitment from diverse stakeholders. The US Future of Nursing: Campaign for Action is guided by an illustrious, nonpartisan strategic advisory committee. It includes diverse stakeholders and outreach to policy makers across party lines. It has formed locally-based Action Coalitions across the country to mobilize a broad-based effort to push for changes at the national, state, and regional levels. It includes a communications plan, grantmaking, and a research, monitoring, and evaluating strategy to generate additional evidence in support of the campaign objectives and ensure accountability by fully gauging our successes and shortcomings.

The Center to Champion Nursing in America is also charged with providing a wide array of technical assistance to ensure that the Action Coalitions are able to implement changes in education, practice, leadership, interprofessional education, diversity, and data. The center is helping Action Coalitions communicate with one another through an extranet—a place to share online discussion, documents, and resources; weekly campaign updates; training; on-the-ground expert consultation; and opportunities for peer-to-peer collaboration though learning collaboratives.

The Campaign for Action has made much progress over the past year. Many national organizations publicly support the report and its recommendations in meaningful ways. These organizations include Aetna, American Red Cross, Healthcare Information and Management Systems Society, National Association of Hispanic Nurses, National Association of Public Hospitals and Health Systems, National Medical Association, and the World Health Organization. The National Hispanic Medical Association is working with its members on an initiative to improve interdisciplinary education. RWJF, in collaboration with other funders, has launched a research initiative to identify, generate, synthesize, and share evidence essential to implementing the recommendations outlined in the report. This multifunder initiative is designed to increase and focus national attention on a common research agenda tied to the IOM recommendations and to facilitate and coordinate funding activity across a range of sources.

The United States has the chance to transform its system and culture of health care, but only if nurses are better prepared and able to practice and lead to the full extent of their education and training. Through national and local efforts, the Campaign for Action aims to utilize the skills and potential of nurses to effect sweeping change for a health care system that provides seamless, accessible, affordable, and equitable quality care for every American.

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A bipartisan bill that would expand telemedicine services and remote patient monitoring (RPM) through Medicare is making headway in Congress with a projected cost savings of $1.8 billion over the next decade. The legislation could also help cut down the 7.88 billion miles home care workers traveled in 2013 for patient visits.

With the goal of improving quality care and cost savings, the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act will expand the use of telecommunications technologies to deliver health care, health information or health education over a distance. The bill is sponsored by both Democrats and Republicans from the House and Senate and was introduced February 3.

“Telehealth is the future of health care,” Senator Brian Schatz (D-Hawaii) said in a prepared statement. “It saves us money and improves health outcomes. Our bipartisan bill puts us on a path to transform health care delivery, making it less costly and more convenient for patients and providers.”

Roughly 50 health care and aging industry groups and associations have endorsed the bill, including the National Association for Home Care & Hospice (NAHC).

“Telehealth and remote monitoring are important for achieving the goals of value-based care, providing more access to primary care and behavioral health, improving chronic care management and advancing patient engagement,” NAHC and other organizations wrote in a letter of support for the legislation.

The bill would also eliminate many of the current limitations on telehealth use, such as provider site restrictions, geographic limitations and restrictions on which providers can offer these services.

“Connecting people through medical professionals through telehealth and remote patient monitoring provides quality and timely care, helps seniors manage their health, and delivers cost savings,” said Senator Roger Wicker (R-Miss.) in a statement.

The provisions of the bill would open up alternative payment models for use of telehealth for certain patients with chronic conditions. Telehealth and remote patient monitoring services would become basic benefits in Medicare Advantage.

The provisions of the bill include creating a bridge program that would help providers transition to the goals of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS).

The bill’s three major provisions are projected to save $1.8 billion in Medicare costs over the next decade, according to an initial analysis by health care consulting firm Avalere Health.

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The future of healthcare is changing. To so this is a scary time because there is so much uncertainty in the future of healthcare and nursing This is especially the case in the United States were the Affordable Care Act and the HITECH Act are causing drastic change in the way healthcare facilities and providers are reimbursed for the care they provide and the requirements linked to documenting patient care.

Nurses have the ability to make a positive impact on the lives of the patients they serve and the nurses who will come after them more than ever. As costs are cut and more demands are being placed on the shoulders of nurses it’s important that nurses feel empowered to advocate for their needs. Without doing this, many nurses will soon find that they are unable to deliver the level of patient care they see fit.

Since nurses are on the front line of healthcare, we see more of the effects of budget cuts and regulatory requirements. Many leaders in healthcare in their Ivory Towers may think the “get” how all these changes affect patient care, but only the nurses at the bedside really see the full effects. They live and work it everyday.

Unfortunately, many nurses believe that they have to take what they receive. They are so job-scared that instead of advocating for themselves they often do not speak up when they are being expected to meet unrealistic expectations or when they are being treated poorly. They don’t realize that nurse empowerment leads to greater job satisfaction. And many nurses don’t realize is that the choices they make can actually affect the work conditions and job requirements of future nurses. When a nurses chooses to act, or more often, not act, he/she causes a butterfly effect that will effect generations to come.

There’s no escaping the budget cuts that are associated with healthcare reform. They are coming and hospitals and other healthcare organizations are going to react. However, there is escaping the potential negative effects on the nursing profession.

If you’re being asked to care for patients in unsafe working conditions, care for too many patients at the same time, or simply are not being paid a wage you deserve: STAND UP for yourself and for NURSES EVERYWHERE.

Reach deep within yourself and gain the confidence to advocate for yours and the nursing profession. This is critical now, more than ever. The actions that you and your fellow nurses make today will effect the future of nursing and healthcare as a whole.

This is where nurse empowerment comes in. We have got to make sure that nurses feel empowered to speak up when they see problems, feel mistreated, or see others being mistreated. This starts with ourselves.  Because if nurses aren’t empowered to speak up for themselves then how are we going to be empowered to speak up for our patients?

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An Illinois nonunion private healthcare workers’ case, recently heard by the Supreme Court, is putting a magnifying glass to the way such workers operate, and could change the way labor unions operate both within and outside of the home health sector.

In the Harris v. Quinn case, nonunion private home care workers charge their First Amendment rights have been violated because they have been required to pay fees to a union that bargains on their behalf for Medicaid payment.

The National Right to Work Committee Legal Defense Foundation, representing the plaintiffs, is arguing that all public sector bargaining is political, because it deals with state budgets, Healthcare Finance News reports.

“Therefore, if these groups are political, no workers should be forced to pay money into their coffers,” Healthcare Finance News says.

It’s important to note that private home health care is an industry unlike many others, Dorie Seavey, senior policy advisor at PHI National, tells Healthcare Finance News.

When families need services that will be paid by Medicaid or other public funds the family must recruit the worker on their own, rather than contracting with an agency, Seavey says, noting that the private worker is then paid directly through the state.

There are about 800,000 independent home health workers receiving public funds — the fastest growing part of home health care, Seavey says.

Infrastructure is lacking at the home health level, Seavey says, adding the states that allow collective bargaining have seen improvements, such as higher wages, benefit programs, paid vacation and more.

States like Illinois say issues like lack of infrastructure is why they have forced nonunion home health workers to pay into the system, Mark Neuberger, an attorney at the law firm Foley & Lardner LLP, tells Healthcare Finance News.

“If you want to organize at a General Motors factory, you group everyone under the roof,” Neuberger says, adding that home health care doesn’t work that way.

It’s possible the court’s ruling won’t just affect private home care workers in Illinois, but could have a wide-reaching affect on organized labor, industry leaders say.

“If the court were to rule that they couldn’t force workers to pay into the system, it would dramatically reduce both revenue and bargaining power for unions,” Bill Dombi, president of the National Association for Home Care & Hospice, tells Healthcare Finance News. “It could impact other groups’ nonunion workers at state and county offices as well.”

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When patients leave the hospital and return home with home nursing care, they go from highly supportive medical environments with potentially many physicians, nurses, aides and other professionals, to non-medical environments with formal and informal caregiver support frequently supplemented by visits from home care nurses. Patients and caregivers must struggle to absorb confusing and potentially contradictory information imparted both by multiple clinicians prior to discharge from the hospital and by home care nurses. Providers, for their part, often have incomplete understandings of home environments and patient and caregiver capabilities. Despite these difficulties, patients are largely left to themselves, expected to be engaged in their care sufficiently to own and manage their medical conditions. It is a daunting task.

Patient safety at home is as important as patient safety in hospitals. Unsafe conditions in the home can lead to unnecessary or avoidable hospitalizations. Home care decreases costs, improves health outcomes, and reduces hospital stays. Despite these benefits, problems exist. Around 13% of patients enrolled in home care experience an adverse event. The largest proportion of adverse events that occur among home care patients are related to medications, with 20–33% experiencing a medication problem or adverse drug event. Research has found that home care personnel and informal caregivers may play a role in a substantial subset of adverse events that result in hospitalization, although further investigation is needed to understand the nature of the interaction. Insufficient attention to effective communication during transitional care from hospital to home may be one of the factors contributing to these patterns.

Relatively little attention has been paid to the underlying causes of these adverse events and how they might be prevented. Our literature search revealed a limited number of published manuscripts in this domain compared to other settings. To prevent hospital re-admissions, improve patient outcomes and save money, more attention must be paid to home care safety.

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Dublin, Ohio-based ViaQuest, Inc., which earlier this year became the first hospice provider in Ohio to offer its clients a pain management program based on genetic testing, has announced the expansion of the program to include patients with ongoing pain management and behavioral health needs.

Individuals in the ViaQuest Hospice or Home Health programs in Ohio will now be able to receive a genetic test, which will help physicians determine which medications should be administered in the correct dosages and time frames to best meet the patients’ needs.

This individually tailored medicine program, known as pharmacogenetics, uses genetic profiles, combined with data such as physical and environmental characteristics, to more accurately prescribe medication.

“Genetic makeup accounts for 20 to 95 percent of the variability of a drug’s effect,” said Kathy Richard, chief clinical officer of ViaQuest, in a written release. “With a simple mouth swab, the metabolism and ability to process specific medications are assessed to determine the efficacy of a medication for an individual. Currently the U.S. Food and Drug Administration recommends genetic testing on 122 prescribed medications.”

ViaQuest will collect data over the next three years to measure the effectiveness of its program, hoping for improved clinical outcomes, increased medication compliance, lower hospitalization and readmission rates and a cost savings related to decreased adverse drug reactions and ineffective drug therapy.

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We’ve been following the CRE superbug outbreak spread by duodenoscopes that have not been completely sanitized. Now, the Food and Drug Administration (FDA) is making moves to improve the safety of procedures involving these scopes.

The FDA announced recently that it will now require manufacturers to prove that new devices can be reliably cleaned by following manufacturer-issued instructions, according to the Los Angeles Times. The federal organization also released new guidelines for “reprocessing”—or sterilizing—devices.

Of course, the release of these new guidelines means that the FDA hadn’t previously required manufacturers to prove their recommended sterilization practices are effective. Although the hospitals that reported the outbreak say they followed manufacturer recommended sterilization procedures, the FDA never had to evaluate whether those procedures were effective.

FDA regulators also said they have no authority to require manufacturers to redesign the scopes, though it is accelerating its work on new proposed rules for requiring proof that the devices can be cleaned reliably. The FDA’s chief scientist reported that the organization started work on these rules four years ago, but never finalized them.

We’ve also posted an article about a World Health Organization report that stated that without action against superbugs, the world may be heading into a “post-antibiotic era.” Fortunately, many advances in cleaning techniques have emerged in recent years, including fighting superbugs with computers and new sterilization techniques using UV light.

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When hospitals update their procedures, they focus first on securing state-of-the-art medical technology and the latest treatments that provide the best outlook for their patients. While the quality of healthcare achieved with these measures is important, another essential part of hospital care is patient engagement.

New technology allows hospitals to interact with patients in a multitude of ways. Today, from before they even set foot inside the hospital to after they’ve gone, patient to staff engagement increases every step of the way.

The days of moving people in and out of the hospital at a brisk pace are gone in favor of creating a comprehensive experience that involves providing educational materials, confirming appointments across multiple platforms and allowing patients to participate in their care in new ways. This makes it easy for patients to stay connected with the hospital staff for as long as they need, and helps them stay informed throughout the whole process.

Mobile Updates

Multi-platform communications that include mobile technology are a growing trend, particularly for younger patients and the parents of children. This provides the ability to deliver information in a streamlined way to patients via methods convenient for them (along with saving a few trees in the process).

Incorporating mobile updates also has the benefit of providing new ways to return to old information, such as recorded discharge instructions that patients can return to and hear exactly what the medical professionals recommended word for word.

Enhanced Care through Applications

Enhanced patient care also applies to the procedures performed within the hospitals. New applications allow for constantly updated online medical records that can offer more thorough views of the needs of the patient. Patient-specific information and requirements were previously prone to getting lost in the shuffle when care was transferred from one person to another, but modern applications help prevent these losses by creating documents that can be updated by all staff members.

This can work wonders for medication adherence. By combining these services with applications tied to pharmacies and medication tracking software, hospitals can get a complete view of which prescriptions were filled and how often the patient is taking their medicine. This is a game-changer for hospitals, as poor medication adherence is a common occurrence and one that causes significant redundancy within hospital operations.

While these new technologies offer big advantages in hospital administration, they aren’t without their drawbacks. Adding new procedures can complicate an already complex system by promoting multiple means of communication with patients and within the practice. Hospitals may wish to move toward electronic means of servicing patients, but remain firmly rooted in the traditional processes of paper charts and educational handouts. Medical practices are notoriously slow to change, which creates confusion for patients told to utilize both old and new forms of communication.

Despite the burden that new procedures place on hospital infrastructure, the importance of utilizing the technological advantage to boost patient interaction shouldn’t be overlooked. By using applications that can provide a complete view of the patient experience, hospitals can manage the care of their clients more effectively than ever before. The patients will appreciate this, as they’ll be able to be kept in the loop throughout the whole process and have more confidence that their care is being managed effectively.

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