In 2010, the Institute of Medicine (IOM), in partnership with the Robert Wood Johnson Foundation (RWJF), released a report on the future of nursing that advocated significantly expanding the role of nurses in the evolving health care system.
This year, a new IOM committee is evaluating the impact of The Future of Nursing: Leading Change, Advancing Health(www.nationalacademies.org) at the report's five-year mark. On May 28, the evaluation committee convened an information-gathering meeting in Washington to discuss progress on the report's eight recommendations (see box below). The committee also invited key stakeholders, including the AAFP and the American College of Physicians (ACP), to present on the topic.
Representatives of three nursing organizations and Kaiser Permanente joined AAFP President Robert Wergin, M.D., and ACP EVP Steven Weinberger, M.D., as part of a stakeholder panel that focused on delivery of care.
The Team Approach
In his comments, Wergin, who maintains a full-scope practice in rural Milford, Neb., first set the stage by describing the evolving health care landscape.
- During a May 28 meeting, AAFP President Robert Wergin, M.D., spoke before an Institute of Medicine committee charged with evaluating the impact of The Future of Nursing: Leading Change, Advancing Health five years after the report's release.
- Team-based care in the patient-centered medical home is integral to the evolving U.S. health care system, Wergin told the committee.
- Wergin also emphasized that tomorrow's health care professionals must learn in an interprofessional educational environment so they can function effectively as part of a practicing health care team.
"We're in the midst of a historic change as we shed the last century's focus on an institutional- and health professional-centric system in favor of a more appropriate (focus on) patient-centered care," said Wergin.
That care will be high quality, comprehensive and coordinated to prevent illness and avoid complications of existing conditions, he continued. "In doing so, it will help save money for the patient, for our communities and for the country, as well as improve population health."
But how do we get there? "With team-based care that embraces each patient with expertise and services tailored to his or her specific needs," said Wergin. "It ensures each patient gets the right care at the right time from the right health professional."
Team-based care in the patient-centered medical home (PCMH) is integral to the new system, he added, and family medicine has embraced the PCMH for more than a decade.
In recent years, though, the pace of progress in promoting that model has accelerated. "Since 2010, implementation of the (Patient Protection and) Affordable Care Act has laid the foundation by testing the efficacy of paying for outcomes instead of procedures and volume," Wergin said. "Most recently, the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act put alternative models of health care delivery, such as the patient-centered medical home, at the forefront of health care reform -- it's actually mentioned in the bill."
Wergin pointed out that this pay-for-performance model has one goal: to support the triple aim of improving population health and the patient experience while at the same time reducing costs.
"No doubt, the 2010 IOM report added to the literature that is moving health policy towards ensuring that we provide the right care at the right time with the right health professional," he said.
In addition to the evolution of team-based, collaborative care in the PCMH, the IOM report emphasized improving nursing education for all nurses, Wergin noted. "The AAFP supports these recommendations because we need a comprehensive, national primary care workforce policy in this country, and this approach moves us in that direction."
IOM Nursing Report
The Institute of Medicine's 2010 Future of Nursing: Leading Change, Advancing Health(www.nationalacademies.org) report made eight recommendations:
- Remove scope-of-practice barriers.
- Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.
- Implement nurse residency programs.
- Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.
- Double the number of nurses with a doctorate by 2020.
- Ensure that nurses engage in lifelong learning.
- Prepare and enable nurses to lead change to advance health.
- Build an infrastructure for the collection and analysis of interprofessional health care workforce data.
Most of these recommendations represent, by their very nature, long-term goals, and work on them is ongoing. Of the two time-limited recommendations, data suggest that nursing appears to be on track to double the number of nurses with a doctorate by 2020. The other recommendation, however -- increasing the proportion of nurses with a baccalaureate degree to 80 percent by 2020 -- may be difficult to achieve.
Furthermore, tomorrow's health care professionals must learn in an interprofessional educational environment so they can function effectively as part of a practicing health care team, Wergin said. The AAFP is a founding member of the Patient-Centered Primary Care Collaborative, which encourages and publicizes educational programs that train primary care physicians, nurse practitioners, nurses, social workers, behavioral health professionals, dietitians and pharmacists, all as part of an interprofessional team.
Wergin also drew the IOM committee's attention to research conducted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care on the structure of effective and efficient health care teams. The center's 2010 report for the Agency for Healthcare Research and Quality showed that patients have the lowest costs, fewest ambulatory care-sensitive hospitalizations and fewest hospital discharges when their community has one physician for every 0.83 nurse practitioners.
In closing, Wergin noted that family physicians, nurses and nurse practitioners have a long history of working collaboratively on behalf of their patients. "The patients are the ultimate beneficiaries when this happens," he said.
"With continued progress in health care system reform, educational collaboration and practice transformation, we will see a health care delivery system that truly serves our patients."
Internal Medicine's Take
Weinberger also focused his remarks on the importance of team-based care, as well as on the ACP's actions after the IOM report came out in 2010.
"We were really quite concerned with some of the reaction from the physician community," he said. "As people are aware, there was a fair amount of negative reaction."
In response, ACP officials took steps to initiate a dialogue in a group that included both physician and nurse leaders, with the help of the RWJF. "It was actually an amazing group," said Weinberger. Unfortunately, the AMA got wind of what the group was doing, and the group's efforts ground to a halt.
"I think a lot of terrific work -- which happens when you can get people in the same room talking to each other -- a lot of that work unfortunately went to naught," Weinberger said. "But it did, I think, create a good relationship, at least certainly with the individuals there, and a commitment to make things smooth moving forward."
Weinberger sketched key points of the policy paper on clinical care teams that the ACP subsequently developed, which includes organizing patient care responsibilities based on the best interests of the patient.
"We felt there is some problem with the concept of leadership, and I will say personally that I would love to see that word kind of go away, because it implies a hierarchy with a higher-up group and a not-so-high group," Weinberger said. Instead, the issue is "who is the point person for a given patient's care, and that is context-driven at a particular time," he added.
Weinberger also spoke about the issue of independent practice. "We certainly feel very strongly that physicians and nurse practitioners and other nurses should work ideally as teams," he said. "But our paper says quite clearly (that) we recognize the need for flexibility, particularly in different settings, rural settings, areas where there are not physicians around. We have to keep the patient's interests in mind and provide care appropriately for this."
The ACP recognizes that health care professionals should be able to practice at the top of their level of training and experience, Weinberger said. "At the same time, it's everyone's professional responsibility not to go beyond that level. It's true for nurses. It's true for physicians. It's true for everyone."
He ended by saying it's important that the nursing profession not be too far out in front, which can create more pushback from the medical profession. "I think the way we avoid this is by increasing communication and collaboration," he said. "We have tried to work and collaborate with the American Association of Nurse Practitioners in a number of areas. I think it has been very successful, and we hope to continue that."
The Red Herring
In a question-and-answer session that followed the presentations, evaluation committee member Richard Berman, M.H.A., M.B.A., specifically asked panel members a question about "the red flag and the red herring" that often provokes emotion when it's discussed: independent practice. "Do we have anything to learn from these five years of that sort of discussion?" he said.
Catherine Dower, J.D., director of national nursing research and policy at Kaiser Permanente and a member of the committee that prepared the IOM nursing report, responded first.
"The use of the term 'independence,' while it can be interpreted lots of different ways, was about full-practice authority," she said. "It wasn't ever meant to be -- and I certainly can't speak for the entire committee -- but I don't think it was meant to mean that people would ever be practicing alone. We wouldn't expect a physician to practice alone.
"The idea was that someone could make decisions based on their competence, training and credentials -- that they could make decisions relatively independently -- but everybody was always expected to practice collaboratively, in integrated systems, in team models, with peers."
Pamela Cipriano, R.N., Ph.D., president of the American Nurses Association, built on Dower's comments. "I would add that, in general, the nursing movement has moved away from using that word independent … because it is a lightning rod and can be misinterpreted."
Team care is really critical, albeit with unnecessary supervision removed, she added. "We wholeheartedly support the need for team-based care."
After the event, Wergin told AAFP News he was pleased to hear very little inflammatory rhetoric during the meeting. "That kind of rhetoric doesn't really get us ahead," he said.
He also said he was pleased to hear all the support for team-based care. However, he said, interpretation of what a team is can make a difference.
"For a nurse practitioner, the question is, 'How comprehensive can you be with the scope of training you've had?'" Wergin observed. "If your interpretation of team-based care is referring often to an orthopedist and a dermatologist, but not to a primary care physician, that's not really a team, that's a formula for fragmentation. And if you fragment, outcomes are worse and costs are higher."
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