The Future of Nursing: Are the Stars Aligning?

APNA 25th Annual Conference October 22, 2011 - Session 4001 The Future of Nursing: Are the Stars Aligning? Catherine Dower $2 ½ 4th-8th 17% trillion 30+ million 100,000/25,000/10,000 2700 million #111+ 37/190 19/19 Anaheim, CA October 22, 2011 2011 Dower My mom Catherine works at UCSF. She studies different doctor s offices around the US, and tries to improve their work and health laws through reports (oral, as well as written). Explore with me what nursing s future may be in context of... Change drivers PPACA IOM Report Dower 1

400 300 200 100 0 MD/100K 400 300 200 100 0 MD/100K APNA 25th Annual Conference October 22, 2011 - Session 4001 2008 Percent GDP to Health Care 20% 16.2% 11.0% 10% Costs 0% US EU Avg Consumers US % Bankruptcies due to Medical Bills 70 60 50 40 30 20 10 0 2001 2007 Life Expectancy at Birth, US Demographic shifts 90 80 70 60 50 40 30 20 10 0 80.4 79.5 75.3 80.4 75.2 71.1 74.1 65.6 46.3 48.3 1900 1950 2000 2004 2007 Men Women US Population Growth 36% Market 178 360 18% 2010 30 2010 50 Source: US Census, 2008 Population Summary & 2010 Population Estimates Baicker & Chandra, Health Affairs 2004 Technology Patient Protection and Affordable Care Act Dower 2

Five ACA categories relate to our work Coverage Financing Innovations in Care Delivery Workforce Pay for quality Financing: Provider payment policies Google searches for Accountable Care Organizations September 2010: 346,000 results. January 2011 1,300,000 results. October 2011: 4,200,000 results Expand Coverage Tying payment to quality Patient-Centered Medical/Health Homes Workforce Supply and Demand Nurse Practitioners, 19% Physician Assistants, 7% Innovative Practice Models Community Clinics Nurse-Managed Health Clinics School-based clinics Sites using telehealth Physicians, 74% Dower 3

Committee s Vision IOM Report The committee envisions a future system that makes quality care accessible to the diverse populations of the United States, intentionally ypromotes wellness and disease prevention, reliably improves health outcomes, and provides compassionate care across the lifespan. In this envisioned future, primary care and prevention are central drivers of the health care system. Interprofessional collaboration and coordination are the norm. Payment for health care services rewards value, not volume of services, and quality care is provided at a price that is affordable for both individuals and society. The rate of growth of health care expenditures slows. In all these areas, the health care system consistently demonstrates that it is responsive to individuals needs and desires through the delivery of truly patient-centered care. Dower 4

COMMITTEE ON THE ROBERT WOOD JOHNSON FOUNDATION INITIATIVE ON THE FUTURE OF NURSING, AT THE INSTITUTE OF MEDICINE Donna E. Shalala (Chair), President, University of Miami Linda Burnes Bolton (Vice Chair), Vice President and Chief Nursing Officer, Cedars-Sinai Health System and Research Institute, Los Angeles, CA Michael R. Bleich, Dean and Dr. Carol A. Lindeman Distinguished Professor, Vice Provost for Interprofessional Education and Development Oregon Health and Science University School of Nursing, Portland Troyen A. Brennan, Executive Vice President, Chief Medical Officer, CVS Caremark, Woonsocket, RI Robert E. Campbell, Vice Chairman (Retired), Johnson & Johnson, New Brunswick, NJ Leah Devlin, Professor of the Practice, University of North Carolina School of Public Health, Raleigh Catherine Dower, Associate Director of Research, Center for the Health Professions, University of California, San Francisco Rosa Gonzalez-Guarda, Guarda Assistant Professor, School of Nursing and Health Studies, University of Miami David C. Goodman, Professor of Pediatric and of Community and Family Medicine, Children s Hospital at Dartmouth, The Dartmouth Institute for Policy and Clinical Practice, Hanover, NH Jennie Chin Hansen, Chief Executive Officer, American Geriatrics Society, New York, NY C. Martin Harris, Chief Information Officer, Cleveland Clinic, Cleveland, OH Anjli Aurora Hinman, Alumni Chair, Health Students Taking Action Together, Duluth, GA William D. Novelli, Distinguished Professor, McDonough School of Business, Georgetown University, Washington, DC Liana Orsolini-Hain, Nursing Instructor, City College of San Francisco, CA Yolanda Partida, Director, National Center, Hablamos Juntos, UCSF Fresno Center for Medical Education and Research, Fresno, CA Robert D. Reischauer, President, The Urban Institute, Washington, DC John W. Rowe, Professor, Mailman School of Public, Health Department of Health Policy and Management, Columbia University, New York, NY Bruce C. Vladeck, Senior Advisor, Nexera Consulting, New York, NY Scope of practice laws are state- based and politically driven Key Messages 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and an improved information infrastructure. resulting in state variability and unnecessary limitations on practice. Key Message #1. Nurses should practice to the full extent of their education and training. Best example of poor match in US is NPs The variability of scope-of-practice regulations across states may hinder advanced practice nurses from giving care they were trained to provide and contributing to innovative health care delivery solutions. Although some states have regulations that allow nurse practitioners to see patients and prescribe medications without a physician s supervision, a majority of states do not. The federal government is well suited to promote reform of states scope-of-practice laws by sharing and providing incentives for the adoption of best practices. 20 3 7 11 10 No MD Involvement No MD Involvement except for Rx MD Supervision & collaboration MD Supervision MD Collaboration Dower 5

Requirements for physician nurse collaboration, 2010 California uses a waiver process to test new scopes of practice NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician. SOURCE: AARP, 2010b. Courtesy of AARP. All rights reserved. Source: Center for the Health Professions, UCSF 2010 Evidence pyramid gives guidance. Exclusive scopes of practice exacerbate interprofessional tensions. Metaanalyses Controlled trials Demonstrations Research studies Government data, OIG reports State laws & regulations Educational curricula, accreditation standards Survey articles, state studies Expert opinion, opinion pieces, anecdotes 2008 UCSF Center for the Health Professions Several states have new ways to help decide scope issues. Recommendation # 1 Remove Scope of Practice Barriers Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends actions for the following entities: State Legislatures Congress Centers for Medicare and Medicaid Services Office of Personnel Management Federal Trade Commission and Antitrust Division of the Department of Justice Dower 6

Citizen Advocacy Center 2 nd Quarter 2010 Recommendations # 3, 4, 5, 6 Implement nurse residency programs Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. Double the number of nurses with a doctorate by 2020. Ensure that nurses engage in lifelong learning www.cacenter.org Recommendation # 2 Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices. Key Message #3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. As leaders, nurses must: Act as full partners with other health care professionals Be accountable for their responsibility to deliver highquality care. Work collaboratively with leaders from other health professions. Identify and propose solutions to problems in care environments Devise and implement plans for improvement Participate in health policy decision-making. Key Message #2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. To ensure the delivery of safe, patient-centered care across settings, an improved nursing education system is critical. To respond to changing patient needs and an evolving health care system, nurses must achieve higher levels of education and training. Education should include opportunities for seamless transition into higher degree programs. Recommendation # 7 Prepare and enable nurses to lead change to advance health Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, els while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses. Dower 7

Key Message #4.Effective workforce planning and policy making require better data collection and an improved information infrastructure. Planning for changes in the education and deployment of the nursing workforce will require comprehensive data on the numbers and types of health care providers currently available and required to meet future needs. Once an infrastructure for collecting and analyzing workforce data is in place, systematic assessment and projection of nursing workforce requirements will be needed to inform necessary changes in nursing practice and education. A priority should be placed on systematic monitoring of the supply of health care workers across professions, review of the data, and methods needed to develop accurate predictions of future workforce needs. Keep it Easy: Link short, focused surveys to re-licensure. Recommendation # 8 Build an infrastructure for the collection and analysis of interprofessional health care workforce data. Keep it electronic: Collect and manage the data online. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible. Collecting workforce data at licensing and renewal is most valuable if it s 1.Easy 2.Electronic 3.Evenly applied Keep it Evenly Applied: Standard data permit trend and comparison analyses. Dower 8

Change drivers, PPACA and IOM Report will create new care practice models New models will push providers and consumers to rethink how and where care is delivered. Three Take- Away Themes New models will push for expanded scopes of practice New models will encourage shift from acute and specialty care to Management of chronic conditions Primary care and care coordination Integration of mental & behavioral health into physical care Prevention and wellness Prevention of adverse events INTEGRATION Dower 9

APNA 25th Annual Conference October 22, 2011 - Session 4001 ACCOUNTABILITY CREATIVITY Catherine Dower Understanding how the future of nursing fits into current health care context provides tremendous opportunity. PPACA IOM Change Drivers UCSF Center for the Health Professions http://futurehealth.ucsf.edu (415) 476-1894 cdower@thecenter.ucsf.edu 2011 Dower Dower 10