Health Care Delivery Reform and the Role of Nurses: Impact on Consumers, Payers and Providers

July 28, 2010 | Washington, DC

Remarks to the Champion Nursing Coalition
---John Rother, AARP Executive Vice President for Policy and Strategy

First of all I want to thank Dr. Susan Reinhard for her leadership in raising awareness about the role of nurses in health care reform and who serves as founder and Chief Strategist for the Center to Champion Nursingin America

I also want to thank Dr. Brenda Cleary, who works with Susan to direct the Center.

We’re also grateful to the Robert Wood Johnson Foundation, especially Dr. Sue Hassmiller, for her leadership on this issue and for partnering with AARP and the AARP Foundation.
 
Today I want to talk about where we need to go in health care delivery – and why that will require a much larger role for the nursing profession.

This is extremely important. The success of health reform depends on innovations in delivery that increase efficiency while maintaining quality.

This is about making health care reform work for patients, for providers, for payers.

The new health care law takes some important steps in the right direction. But it doesn’t go far enough.

Stakeholders need to work together, and we’re encouraged at signs they will. The challenge is too big for any one group alone.  A great deal more needs to be done.

We want to make sure that under-served communities get access to the primary care that they need.

We want a system that takes a holistic view of well-being for ALL patients, and puts that goal at the very center.

So what does that mean?

• Care needs to be coordinated.
• Wellness and prevention have to become much higher priorities.
• Clinicians need to communicate effectively with patients – and each other.
• Patients and caregivers need more support, and that includes support in making decisions.

The reality is that many Americans have a very different experience with the health care system.

Patients often feel adrift. They lack guidance when they face transitions from hospitals to home, and they’re uncertain how to manage their own health issues.

In fact, one in three patients say they frequently or occasionally feel confused about what to do after they leave their provider or the hospital. 
 
Patients also lack knowledge about community resources to help them stay independent, a subject that providers usually do not bring up.

No wonder so many end up back in the hospital. And we know that hospitals want to address this. Unplanned readmissions cost the system more than $17 billion year -- not to mention great personal disruption for patients and their families.

And we all agree that patient safety is a big concern. For example, 100,000 people die in hospitals every year from infections they pick up while there.

An epidemic of chronic conditions is bringing all these problems home to more and more individuals, and placing increasing strain on the system itself.

Nationally, more than 70 million Americans age 50-plus – that’s four out of five older adults – have at least one chronic condition.

Five chronic diseases are responsible for more than 75% of the nation’s health care expenditures: diabetes, congestive heart failure, coronary artery disease, asthma, and depression.

According to the Department of Health and Human Services, 27% of the population struggles with more than one chronic condition.

Meanwhile, some of the trends are going in the wrong direction.

According to the Center for Disease Control, obesity in this country has gone up from 23% in the early 1990s to about 34% today.

More than a quarter of young adults weigh too much to serve in the military.
 
And we know that obesity can exacerbate other conditions like diabetes.

Meanwhile, 76 million boomers are getting older.

The epidemic of chronic conditions is placing increased demands on the delivery system.

We’re facing a very big challenge.

The new health care law supports some initiatives that can point the way to innovations we need.

Various pilot projects will test ways to improve coordination.

These efforts will emphasize teamwork and collaboration across disciplines.

They will seek financial incentives that reward providers for quality of care rather than for quantity.

• Patient-centered medical homes emphasize primary care and the importance of expert clinicians and coordinators who can help patients navigate the labyrinth of health care.
• Accountable care organizations will try to give providers a shared financial incentive for efficiency and quality.
• Another initiative will target high rates of readmissions, by providing transitional services to help patients and their families manage their conditions and stay out of the hospital.

We're also pleased that the new law provides more funding for primary care and community-based health centers. These funds are desperately needed.
But we have to be realistic.

A great deal more will have to be done to establish the health care system this country needs -- and to keep it sustainable.

We need to build – and empower -- a health care work force that meets the real needs of patients. This is absolutely essential if we’re going to provide quality care that is also efficient.

We need to make much greater use of the skills of ALL health care professionals.

We can't rely on physicians to do it all, nor should we.

The nursing profession has a tremendous leadership role to play in this effort.

The skills of nurses in providing care, in managing, in communicating, in teaching and counseling can help transform the delivery system.

Nurses can deliver, coordinate and direct care in a whole range of settings.

Nurse-led models of care have been demonstrated to cut costs and increase access. We don’t need to test them. They have a proven track record.

Nurse practitioners can actually reduce the length of hospital stays. Nurse-led clinics can play a much larger role in prevention and promoting wellness.

Highly-skilled nurses can help address problems of waste, overuse and misuse that drive up costs and undermine health.

Nurses can play leading roles in delivery models like Medical Homes and Accountable Care Organizations.

We also need advanced practice registered nurses to help fill the void in primary care.

Expanded coverage does not translate to meaningful access, especially for the under-served who have few convenient options for quality care.

As a nation, we need a long-term investment in community-based models to bring health care to the underserved and replace the harmful reliance on emergency rooms. Health care reform is going to put new strain on the system. We expect the new law to bring coverage to 32 million people who are currently shut out.

One thing we’ve learned from the Massachusetts experience is we have to plan now to make sure we have the workforce to care for them. Highly skilled nurses are absolutely essential to meeting this need.

The fact is that advanced practice registered nurses can do a great many things that will enhance patient well-being and provide efficient care.

I’m talking about things like helping manage chronic conditions, guiding patients through transitions, coordinating services, promoting wellness and prevention. 

Advanced practice registered nurses can run public clinics in places where primary care is just a fantasy.

Nurses can provide the geriatric services that our aging population is going to need more and more in the coming years.

If not nurses, WHO’S going to do it?

Nurses have a critical role in making expanded access meaningful. But none of these vital contributions can take place on the scale that’s needed, unless we eliminate the barriers that stand in the way.

We need to take a hard look at state laws and rules that limit the ability of consumers to access the full range of nurses’ skills and experience.

Out-dated restrictions on advanced practice nursing hurt the whole system. They limit access to cost-effective, quality care. They limit our capacity to launch new programs by holding back expertise we need to make use of.

We urge state governments to review their laws and regulations so all can benefit from the most enlightened policies already in effect.

We want state laws to be more consistent. 

Not a single study has established a basis for requiring physicians to supervise advanced practice nurses. Yet such requirements are widespread and add unnecessary costs for consumers and payers.

Federal rules also impede the ability of nurses to work up to their full qualifications and help provide comprehensive, coordinated primary care.

It’s time to modernize those provisions. 

We also need to educate more nurses and nurse faculty. The new law will help, but we should do more to break down barriers. We must:

1. Increase our ability to graduate more highly skilled nurses. This will require more faculty and effective use of technology and other resources.
2. Ensure nurses can more quickly and smoothly move through educational and practice pathways.
3. Expand diversity of nurses and nurse-educators to help make sure the workforce has the cultural competencies that are needed.

In conclusion, ALL stakeholders will benefit from a transformed health care system in which nurses play a much larger role.

This is a very big issue. This really goes to the heart of whether health reform can reach its potential for the good of society.

Establishing the workforce we need – and using it productively -- will enhance delivery, improve outcomes, and help contain costs.

Improving delivery of care will help not only patients but also payers and providers.

This is why AARP joined the Champion Nursing Coalition. We believe that our members and their families – and all Americans -- will benefit from access to a highly-skilled nursing workforce. I want to thank those of

you here today who already have joined us in this effort and encourage those of you who have not yet joined to do so.

Nurses are essential to keeping the system sustainable for the long haul.

Thank you.

References
 - National Council on Aging and Lake Research Partners, Reforming Healthcare: Americans Speak Out About Chronic Conditions and Challenges to Self-Care, in Findings From a National Survey of Americans 44 and Older with Chronic Conditions. 2009.
 - Consumer Reports Poll: More Americans Acquiring Medical Infections and Experiencing Medical Errors," 4/14/2009
 - AARP's Public Policy Institute  
 - Washington Post, June 17, 2010, Lenny Bernstein, “Too fat to fight? Military recruits and obesity”