From Tradition to Transformation:

From Tradition to Transformation: A Revolutionary Moment for Nursing in the Age of Reform Tim Porter-O Grady, DM, EdD, ScD(h), APRN, FAAN, FACCWS A NEW SCRIPT FOR HEALTHCARE The Patient Protection and Affordable Care Act (PPACA) provides an entirely new framework for the delivery of healthcare in the United States. 1 Through its many provisions, the PPACA transforms the very foundations of traditional American healthcare and changes the focus from late-stage, high-intensity, illness-focused, tertiary, interventional health service to a much stronger valuedriven focus on achieving the highest levels health for communities and populations. 2 Beginning to refocus on episodes, population, and continua of health services, the PPACA refocuses the efforts of providers from emphasizing volume-based incidences of service to valuedriven integration of care. This notion of integrating care along the continuum of services for individuals and providing an aggregated service framework for populations of users creates an entirely different structural context for the delivery of healthcare. The emphasis on achieving value-based care, continuum of service best-choices, and efficient and effective alignment of activities with impact creates the need for a goodnessof-fit between efficient and effective clinical processes and related desirable clinical outcomes. Increasingly, the growing evidentiary foundations for the delivery of effective healthcare will require a better developed set of practice dynamics that reflect a far more relevant and current approach to just-in-time adjustments and improvements in care as data aggregation suggests increasingly accelerating best practices. 3 THE CALL FOR TRANSFORMING NURSING PRACTICE Much of the historic foundations of nursing practice for the past 60 years are grounded in institutional and fixed models of service delivery based on the medical model. Many of the activities of nursing are reflective of high-intensity, highengagement, acute, late-stage interventions usually in a limited adaptive sickness care model. The very elements of nursing education and practice were founded in a linear hospital-based institutional practice format that was (and still is) highly incremental, compartmentalized, segmented, and iterative. 4 For the most part, the ability to really attend to the health or continuing needs of individual patients was structurally impeded by a highly segmented, distributed set of service delivery silos with a highly variable linkage capacity with other segments of the care delivery system upon which they were dependent or with which they were related. 5 As a result, nursing transitioned to a fixed practice model that is represented by siteor location-specific role delineations, highly structured functional processes, a narrowly prescribed capacity for critical judgment, and performance factors that represent a predominant focus on ritual and routine. Although this has not www.nurseleader.com Nurse Leader 65

changed for the vast majority of registered nurses over the past 60 years, the advent of advanced practice nursing has provided a broader scope of practice that does more fully utilize the full critical knowledge range and application of professional nurses. However, even here, the notion that that role should be fully subscribed pushes against the medical model that has worked diligently to circumscribe or contain the role as a subset of medical ascendancy and in the majority of states under varying degrees of medical legal control. 6 The PPACA challenges much of the more traditional delineations of roles and function in healthcare. The expectations of the PPACA represent a shifting foundation for American healthcare and lead to the potential for different roles and relationships in the delivery of health service. The emphasis of the Act on health and prevention shifts the locus of control from illness to health. Emphasizing the health continuum as evidenced by focus on integration, populations, whole episodes of service, and the continuum of health, a new refocused emphasis on avoiding high-intensity, highintervention, late-stage access of health services emerges as the driver of health services. 7 Furthermore, value-based purchasing or care creates a framework for the delivery of service that rewards the provider s ability to achieve and sustain a net aggregate best level of health within populations, and/or episodes of service creates a different goal-set for providers and real lines how they are paid for that work. Essentially focusing on establishing a value basis for achieving health goals and attaching rewards and incentives to that dynamic, shifts the foundations for both health service and payment. Further, creating payment structures for particular bundled services in specific episodes of care increases the collateral and relational accountability of linked, continuum-based services negotiated between service and care partners in a single pricing algorithm. 8 CHANGING CARE DELIVERY; TRANSFORMING NURSING PRACTICE It is not a significant stretch for providers to realize that this approach to health service provision changes both the focus in the character of service/care delivery. An unambiguous focus on early-engagement, low-intensity, high-relationship, high-accountability interaction between providers and with patients and populations becomes increasingly central to advancing health, achieving some measure of value, and more positively assuring a cost-effective and sustainable health system. Although hospitals and health systems are currently working diligently to capture physicians and physician practices in order to lay the groundwork for better control and integration of medical and health services as an effort to create essential partnerships, much of the truly cost-effective efforts in this paradigm will be found elsewhere. Indeed, the role of the nurse will demonstrate a much more defined value in the reformed health system than at any time in its history simply because of economies of scale, well-established competencies in integrating, coordinating, and facilitating interactions and relationships at the level of patient care, and the location of professional nursing at the interface of the relationship between all health professionals and the patient. The location of nursing at the intersections of the health system uniquely position nurses to assume the role of navigator between service providers, patients, and populations. This circumstance requires only that nurses develop a deeper awareness of their role in the value trajectory in health-based services and, in anticipation of this role, prepare the profession to assume the appropriate obligations of the expression of this role. Some of the critical considerations with regard to significant changes in nursing practice that nurse leaders must address are: 1. The growing role of population and patient-driven health education and development providing a broader understanding of personal health practices and their role in the prevention of subsequent health challenges. 2. Contextualizing the nursing role along the continuum of the patient s or population s health journey reflecting basic mobility attributes in the nursing role in a way that schedules, locates, and assigns nurses in a variety of settings along the continuum of a particular episode of care, population health need, or service continuum. 3. Re-emphasize and retool practicing nurses to exercise more interdependent critical clinical judgment that honors the standards and principles of care yet specifically customizes the practices of care to the unique individual, cultural, social, economic, and physiological characteristics of individuals and populations. The heretofore growing trend that focuses on standardization of practice now needs to reflect a far deeper dive into the adaptation, customization, and individualization of nursing and health practices in order to ensure a more user-specific ownership of health practices resulting in a stronger value exchange and better tightness-of-fit between process and health outcomes. 4. Strengthen the community, neighborhood, population focus, and role of nurses, moving a major component of the currently predominant hospital-based nursing practices to sites and settings outside the hospital in programs, models, and roles. These roles must engage populations and patients in place in a way that early addresses issues that, later addressed, would ultimately lead to the hospital door. One of the grounding principles of the future of nursing practice reflected in the PPACA is a deeper systematic, organizational, and practice comprehension that admission to the hospital is forthwith a signal of the failure of the healthcare system, not the normative centerpiece of health service provision. 5. More strongly interface nurses with children in school and community settings where early education and development of health practices will prove to have the most significant and lasting impact on later health choices. Nurses will provide care, education, and services to children otherwise disadvantaged by a lack of access to such services. Such lack of access to in-place primary and early health services always leads to later 66 Nurse Leader February 2014

access to higher-cost, higher-intensity clinical interventions for a population who has limited resources to pay for them and whose health options as a result of this dynamic are equally limited. 6. Nursing care and roles must be more judiciously targeted and carefully distributed in order to maximize value and reduce resource intensity. About 6% of the American population currently uses 50% of its health resources. 9 Economies of scale require a more considered and judicious understanding of these populations and their particular needs, and how best to alter the demand equation for clinical services in this population as a strategy to increase the opportunity to broaden the impact and generate the highest cost benefit outcomes. Nursing is increasingly a predominant player in the decision-making arena related to enabling health-advancing choices in populations and patients as a part of an intentional strategy to avoid higher-cost medical intervention specialty services. This dynamic is historically counterintuitive yet now remains one of the central elements influencing the efficacy of health reform. 7. The increasing demand for a health-driven script in the PPACA now requires an accelerated preparation and utilization of primary care practitioners. The medical education establishment, for a variety of reasons, is unable to prepare sufficient medical physician providers in the numbers needed within an appropriate time frame. 10 Nursing has both the capacity and capability to meet American primary care demands with sufficient advanced practice primary care nurses. There is no evidence nor is there any legitimate reason that these primary care advance practice nurses cannot become the principal provider of such services and act as the clinical centerpiece for the future provision of primary care within the PPACA. 11 There is nothing within the PPACA that limits or constrains this potential. 8. There is a growing dependence and need for better educated and more highly prepared nursing professionals. The notion that associate degree education alone is sufficient preparation for the future of nursing practice is inaccurate and shortsighted. Although the associate degree should continue to be a legitimate entry portal into the profession, it must be tethered directly with second-degree nursing education in order to create a sufficient trajectory of development to meet the minimum requisites of future nursing practice within PPACA. 12 In addition, health systems nursing leaders must be committed to providing cost benefit support for the use of bachelor of science in nursing and advanced practice nurses using the evidence of the utility and value of their services in cost reduction and value advancement. Because value, not volume, is the driver of future healthcare performance and payment, nursing leaders play a seminal role in creating algorithms of value that evidence the cost and service benefit of well-prepared, better positioned nursing resources acting to integrate, coordinate, and facilitate value-grounded health service provision. NAVIGATING THE CONTINUUM OF CARE Within the context of health reform, the nurse leader must create a strong culture of intrapreneurial practices and behaviors. Because there is a 180 shift in the focus of health service from illness to health, many of the existent past practices upon which contemporary nursing practice is grounded will need to be challenged and adjusted. This new landscape of innovation will require nurse executive leaders to exhibit the capacity to assess their individual health systems and their capacity to realign, reconfigure, and recalibrate their existing models of illness care delivery for service models driven by a health script. In a more transprofessional, collateral, partnership-driven service delivery model, the collaborative and coordinate of role of the clinical nurse practice leader will emerge as a centerpiece of effective team-driven service approaches. 14 Organizing care around episodes, populations, and continua of care requires equity-based skills in negotiating roles, clarifying expectations, verifying contributions, identifying partnership requisites, delineating accountabilities, and verifying impact and outcome. Although physicians will continue to play critical medical intervention roles, there is no doubt that the highly developed coordination, integration, and facilitation skills of nursing professionals will evolve into the essential navigator roles for population, episode, and continuum design service models. It will without doubt fall to the nursing professional to assure clarity of agreement regarding role contribution, appropriate exercise of partner roles, coordination of transdisciplinary clinical efforts, facilitation of team performance, management and coordination of performance and outcome metrics, and coordination of teambased clinical efforts and impact. Essentially, nurse leaders will need to ensure that practicing nurses are prepared and positioned to fulfill the following obligations: 1. Coordinate the contracted agreement between partner professionals within the episode or population clinical team in a way that ensures clarity regarding role, agreement, expectation, performance, metrics, and team evaluation. 2. Manage the interface between team members at the variety of points-of-convergence between clinical team members in a way that ensures effective coordination of care and seamless handoff of essential functions and activities within each phase of the clinical service delivery continuum. 3. Problem solve issues and concerns with service brokenness or ineffectiveness using just-in-time approaches that are service and time sensitive in order to adequately make adjustments in service activities quickly enough to avoid negative impact on value and payment. 4. Ensure successful and seamless service interface, making judgments regarding service effectiveness and the appropriate calibration of service mix in a way that www.nurseleader.com Nurse Leader 67

determines whether service goals have been achieved and value targets are consistently met. 5. Coordinate the transprofessional team member s efforts to address service variance, clinical process variables, metric discrepancies, patient satisfaction constraints, and any challenges to the achievement and sustenance of team service goals. 6. Quickly adjust any work activities and distribution as immediate and unplanned situations and scenarios arise requiring a shift in expectation, interaction, and performance that affects the value equation and impedes the achievement of episodic, population, or continuum-based clinical service goals. These and a host of other related roles now influence the competence and performance expectations of professional nurses at the clinical point-of-service in every health system. The nurse leader s understanding of the shift from fixed practice models and processes for the delivery of nursing care to more fluid and mobile models of nursing practice within the digitally driven health service environment will be critical to the effectiveness of future nursing practice. Moving from fixed, institutional models of practice (the so-called policy and procedure approach) to more fluid, continuum-grounded models of clinical practice (evidentiary approaches) will require clinical and management leadership to abandon traditional templates of institutional practice and to engage out-of-the-box methodologies to more mobile, collateral, partnered, continuum-based delivery models. Testing these approaches in smaller opportunities for accountable care, episodes of care, or particular patient populations (diabetic, congestive heart failure, obese-geriatric, as examples) will provide a foundational template for experimentation and create exemplars upon which larger, more complex service models can be later constructed. CONFRONTING THE BARRIERS TO ACCOUNTABLE CARE AND TRANSFORMING NURSING PRACTICE Nurse leaders will need to become increasingly aware of the necessary structural shifts that must continue in order to support the dramatic move to continuum-based service models and partnership driven practices. The PPACA call to focus the future of health services on wellness and prevention over the long term, and shift service structures to value-based purchasing and service, provides the foundations for a deeper and longer-term shift in service structures. The hospital as traditionally configured will no longer be the adequate service ground for the future of healthcare delivery. Reconstructing the hospital into a point of integration and generation of the more linked and integrated service continuum will require a number of significant structural shifts. Primary among these are: 1. A user-driven, portable, and aggregating health record that moves with the patient and can be accessed in real time wherever the patient intersects with the health system across any clinical service or information platform is essential to any value-grounded health system. No economies of scale can ever be achieved without an effective service information and data value chain. As competition becomes more intense within the parameters of health value, it will be virtually impossible to be adaptive and respond without an information infrastructure that responds to changes in demand and practice just-in-time, with obtainable and intentional outcomes that can be validated and replicated. Providers need to have the capacity to both obtain and interact with the latest patient-based data, and link and intersect individual clinical contribution with the partnered contributions of other essential members of the patient's clinical team. This seamless integration of the clinical data system is central to any effective and successful model of value-based care. 2. There must be a more effective management of patients in the health system in a way that treats them as members of that system. The notion of exit and entry into the system by its users, or admission and discharge from the health system, creates an interruptive, compartmental, and late-stage notion of the individual's relationship to their own health and to the system that ostensibly supports that health. Individuals must always be in the system, and the health system should follow them at all times. Much like the news pushes (notifications on a cell phone) gives access to every subscriber on their mobile device, the health system must be so connected to the user that it acts as one with the person. Care must be so customized that it intersects in ways that advises and guides the user's health and life choices wherever they might be or whatever health choices they might be making at any point in time. 3. Handoffs become increasingly important in valuebased health reform. Seamless and well-linked handoffs all along the continuum of services implies that the information and clinical system have a high level of interoperability. The system gathers and aggregates knowledge, judgments, resources, and actions that demonstrate a goodness-of-fit between each component of service in the patient s journey in a way that is both service effective and value evident. Wide variations in service and care resulting from inadequate handoff systems is now becoming increasingly untenable as lowered payment becomes the price paid for failing to tightly coordinate and integrate care. 4. Mechanisms for reducing variance within populations, episodes, or processes of patient service will be critical to success in any system of accountable care. Services will be competing on value and will be compared for effectiveness against each other as a mechanism for determining value and as a part of the process of determining value-based payment for comparable care. Those services with the best price quality indices and lowest level of costly service variance will experience the greatest advantage in the value payment algorithm. Here, nursing has the greatest potential for making a difference through the management of variance at any point in the care delivery through good care management within the team and along the continuum of care. 68 Nurse Leader February 2014

5. Both the supply chain and service value chain have huge potential for addressing the range of costs that represent the greatest arena of waste within the health system. Choices related to supplies, tools, inventory, utility, and efficacy of use will be important factors in cost control especially since services will be offered in a wider variety of settings in a multitude of user-driven service settings. Good resource management will increasingly be a part of the point-of-service clinical management process, and clinical providers will play a larger role in carefully managing and moderating resource choices as a part of clinical decision making. 6. Leaders will need to change mechanisms for assigning, scheduling, and staffing nursing resources as models of service change, to address delivery of care in a host of new ways that meet patient needs without predominantly using hospital-based illness services. Newer approaches to employing nurses must emerge, including collateral engagement, engaging nurses in care systems that reflect transdisciplinary partnerships, contracting for deliverables, payment for results rather than process, just-in-time care approaches, and customized care that adapts to unique population and patient characteristics within a bundled pricing framework. The implications of health reform are just now unfolding, especially as they inform choices leaders must make related to organizing the delivery of care services and the best management of resources. However, a template is now emerging with regard to the essential adjustments leaders must now be contemplating in able to best configure response to the emerging demands of health reform and create specific responses to accountable care within PPACA. The movement to creating value for advancing the highest level of health for users of health services and structuring for quality and value as well as paying for both are central to the role of recalibrating how nurses are used and their services are provided. Nurse leaders must now ask a different set of questions regarding the emerging character of the nurse s role in the coordination, integration, and facilitation of value-based care in an accountable care system. 14 Clearly, nurses will accelerate in importance in a healthscripted, value-driven health system. As critical navigators of service along the continuum of care, nurses will add considerable value in managing both the partnerships necessary to rendering truly accountable care and in assuring value-defined measures of quality and sustainable health outcomes. Nurse leaders must see this centrality of the nursing role and demonstrate a capacity to act outside of the industrially structured illness care "box." The time has come for nursing service leaders to innovate both the structure and practice of nursing in a way that demonstrates its centrality to the future of health reform and its capacity to lead the care team into new dynamics and processes of service that lead to real reform, better access, and higher levels of sustainable health for every American. NL 2. Knudson L. Affordable Care Act ruling introduces sweeping changes to healthcare system. AORN J. 2012;96(3):8-9. 3. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practices. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2010. 4. Voyer B. Changes in relations and roles of doctors and nurses. Br J Healthc Manag. 201319(1):16-21. 5. Sweeney A, Rose D, Clements S, et al. Understanding service user-defined continuity of care and its relationship to health and social measures: a crosssectional study. BMC Health Serv Res. 2012;12:145-154. 6. Gardner A, Gardner G. 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J Contin Educ Nurs. 2008;39:307-313. 13. McClellan M, McKethan A, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29:982-990. 14. Mauk J, Breitinger AK. Future of healthcare in America: what nurse leaders need to know about the shifting landscape. Voice Nurs Leadersh. 2013;11(2):8-9. Tim Porter-O Grady, DM, EdD, ScD(h), APRN, FAAN, FAC- CWS, is senior partner of Tim Porter-O Grady Associates, in Atlanta, Georgia. He can be reached at info@tpogassociates.com. 1541-4612/2014/ $ See front matter Copyright 2014 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.08.006 References 1. Sorrell JM. Ethics: the Patient Protection and Affordable Care Act: ethical perspectives in 21st century health care. Online J Issues Nurs. 2012;18(1). doi: 10.3912/OJIN.Vol18No02EthCol01. www.nurseleader.com Nurse Leader 69