Leadership for Public Education

Role Change

Nurses have always coordinated care, but now that it is a healthcare reform priority, they are taking on new roles.

High costs, uneven quality of care and poor patient outcomes are the big problems with healthcare in the United States. The Affordable Care Act is relying on the coordination of care as the solution to these problems. Care coordination is not a new concept, but nurses are critical to its success. They are key to boosting patient satisfaction, quality care and using hospital resources more effectively; and now, the ACA’s focus on care coordination will open new doors for them.

The ACA offers incentives for providers to come together to coordinate care and to create models of care that focus on prevention and management of chronic illness; these models will better utilize the knowledge, skills and abilities of registered nurses and other healthcare professionals, and increase opportunities for advanced practice registered nurses (APRNs) to serve in primary care provider roles. Nurses will play a substantial coordinating role in improving the delivery of healthcare; and helping these professionals step into their new roles is an AFT Healthcare priority.

“The patient gets the biggest benefit of care coordination,” says Melissa Pond, a nurse case manager for Kaiser Permanente in Portland,Ore., and a member of the Oregon Federation of Nurses and Health Professionals (OFNHP).

“We are meeting the patients where they are, making them the center of their care. It is really a self-management plan because it’s about what the patients feel will make their lives better.”

Models vary
There are various care coordination models, but typically case management, care transition programs, disease management, health information technology and other strategies are used to manage service delivery and support patients and providers. The new roles for nurses and other health professionals may also mean new job titles, such as care coordinator, nurse care manager, patient coordinator, guided care nurse or patient navigator. But no matter the name, the main goals of these professionals will be to increase patient satisfaction and to reduce hospital admissions and the cost of care.

Research has shown that care coordination can improve patient outcomes and save money for patients, especially the elderly, as they make the transition from hospital to home. In schools, students with chronic conditions also will benefit from care coordination. One well-known care model uses an interprofessional clinical team and nurse care coordination to educate and empower patients to improve their health.

“The coordination is patient centered and relies on a nurse trained to bring together various aspects of care. The ACA was designed to allow this kind of delivery of healthcare,” says Kathleen Grieve, a nurse, and one of seven original guided care nurses with the Johns Hopkins Bloomberg School of Public Health. In her role as a guided care nurse, she works with older patients for the long term.

Grieve coordinates care for about 60 patients. She stays in touch with them after they leave the hospital and with her help, the patients set their own health goals and follow through with an action plan to achieve those goals. Grieve reaches out to her patients monthly, offering coaching as well as monitoring their medications, exercise and diet.

“It is an enhancement of case management,” says Grieve in describing her work. “The nursing skills make guided care easier. Whereas case management is short-term management, guided care is set up for geriatric patients; the nurses work with patients for the rest of their lives.”

Care coordination is of great help to the patients, says Grieve. “When you leave the hospital, it’s impossible to absorb all the information you get. To have someone who is familiar with the lay of the land, who can guide a patient through it all, is invaluable.”

Grieve also is an instructor for the Institute of Johns Hopkins Nursing, which offers an online course to prepare nurses for guided care. She predicts the number of advanced practice registered nurses and case managers will grow by leaps and bounds.

“I see endless opportunities for nurses,” says Grieve. “Nurses in hospitals and doctors’ offices will always be needed; but these new roles offer another option for a career in nursing.”

Michelle DeLayo, an acute care APRN at the University of Connecticut Health Center and a member of the University Health Professionals, agrees.

DeLayo, who notes that she has seen a shift in support of APRNs by the healthcare community. “There is a change in culture in terms of thinking about what APRNS can do. The tide is changing in our favor.”

The ACA will increase access to insurance coverage, and with a shortage of primary care doctors and a likely increase in the demand for primary care, APRNs will have a chance to provide these services.

APRNs are qualified to practice independently, says DeLayo, who has been an APRN for 10 years. “They can be a link, a bridge to help with the influx of newly insured people,” she says.

“Right now, we have a hard time recruiting nurse practitioners in our unit,” DeLayo adds, but maybe in a few years, the changes the ACA is bringing will increase the pool of APRNs.

Optimal delivery of care
In the hospital, one of the biggest challenges to delivering the best possible care is faulty communication between the provider and the patient, says Grieve. The lack of time providers get to spend with patients is another challenge. “There is not enough time to walk patients through certain processes,” she says, “especially at discharge.”

Being able to coordinate care helps nurses rise to meet those challenges.

“Patients are so grateful that you are reaching out to them,” says Traci D’Andrea, a transition case manager for Kaiser in Portland, Ore., and member of the OFNHP.

D’Andrea works with patients after they have been discharged from the hospital. She follows up with patients, making sure they take the medications and go to appointments with their physicians. She also refers patients for any other care they may require.

When patients are are being discharged, “the only thing they are concerned about is going home, so they may miss something. When I call, it’s a chance for me to go over everything one more time,” says D’Andrea. “Most patients are very thankful that they have one person to call instead of having to reach out to a host of health professionals. They are grateful to have someone who follows up with them.”

Ultimately, the goal is to prevent readmissions, says D’Andrea. (Readmissions can negatively affect a hospital’s reimbursement by Medicare). “I feel like I’m an advocate for the patients, getting them the care they need. In a way we are a navigator, too. We help people navigate through our Kaiser system,” says D’Andrea, who has been a nurse for 33 years and gravitated to transition case management several years ago.

Kathyrn Thompson, a chronic care case manager who also works for Kaiser agrees with D’Andrea. Thompson has been a registered nurse for 34 years and a case manager for the last six of those years. “I’m able to work with the patient fully, and I love the work that I do. We are making a difference in people’s lives, and it’s really rewarding,” she says. “The days of seeing a doctor, getting meds and following up with the doctor are coming to an end. It’s more likely a patient will follow up with a nurse—working from a protocol—who will guide the patient to better health,” says Thompson who is also an OFNHP member.

Immense satisfaction
Hearing that healthcare reform will open up new opportunities for nurses has piqued Joyce Michaud’s curiosity. Her interest stems from a simple fact: You can’t do bedside nursing forever. “Physically, it’s impossible to stay in bedside nursing beyond a certain age,” says Michaud, a registered nurse at the University of Connecticut Health Center’s gastroenterology clinic and a member of University Health Professionals.

Moving into a new field of nursing has its appeal, and care coordination looks particularly good to Michaud because it would allow her to care for the patient in a more holistic way. “Coordinating care is something you always do as a nurse,” says Michaud, “but that part of my job is just a small piece of the care a patient gets.”

Grieve says that her job satisfaction in guided care is immense. “We use our knowledge to enhance our patient’s experience and to help them reduce the stress of getting well.”

She often hears nurses who make the career transition to guided care say, “This is what I went into nursing for,” and patients will say, “It’s like having a nurse in the family.”

“There will be a lot of older nurses transitioning into these roles,” says Grieve, “and most will ask,?‘Why didn’t I do it sooner?’?”