Re­form depend­ing on nurs­ing

Re­form law seeks to dis­trib­ute pri­mary re­sources

Modern Healthcare - - Front Page - Joe Carl­son

Nurses will find their skills in far greater de­mand un­der many of the pro­vi­sions of the Pa­tient Pro­tec­tion and Af­ford­able Care Act, but much of the new ac­tiv­ity will take place out­side the walls of the hos­pi­tal as ef­fi­ciency ef­forts drive more rou­tine care into the home.

The law puts an em­pha­sis on dis­tribut­ing highly ed­u­cated nurses closer to med­i­cally un­der­served pop­u­la­tions. Law­mak­ers also wanted to en­cour­age lesser-trained nurses to go back to school so they can pro­vide pri­mary care or be­come fac­ulty at the many nurs­ing col­leges that still turn away qual­i­fied stu­dents be­cause of a lack of in­struc­tors.

“I would say the nurs­ing or­ga­ni­za­tions are unan­i­mous in sup­port of health­care re­form,” said Su­san Rein­hard, the chief strate­gist with the Cen­ter to Cham­pion Nurs­ing in Amer­ica, an ini­tia­tive of the AARP and the Robert Wood John­son Foun­da­tion.

Nurse lead­ers say they were grat­i­fied to see how the law rec­og­nizes a point they’ve long been ar­gu­ing—that one of the best ways to make the health­care sys­tem more ef­fi­cient is to shift away from episodic, cri­sis-driven health­care and to­ward a sys­tem that re­lies on pri­mary care and pre­ven­tive health main­te­nance to keep peo­ple health­ier be­fore they be­come hos­pi­tal pa­tients. In many cases, that means hav­ing more highly trained nurses di­rectly de­liver care to pa­tients.

For ex­am­ple, Sec­tion 5208 of the law will pump cash into the hun­dreds of nurse­m­an­aged com­mu­nity care clin­ics al­ready op­er­at­ing across the coun­try. “The sup­port that the bill pro­vided to these pro­grams re­ally shined a light on nurs­ing,” said Rose Gon­za­lez, di­rec­tor of govern­ment af­fairs for the Amer­i­can Nurses As­so­ci­a­tion. “The move­ment away from acute care, into more pri­mary care, pre­ven­tion and well­ness is some­thing that has been nurses’ mantra for years.”

The law adds “nurse-man­aged health clin­ics” to the group of health cen­ters el­i­gi­ble to re­ceive up to $50 mil­lion in grants in fis­cal 2010. The clin­ics must be man­aged by ad­vanced prac­tice nurses, pro­vide ser­vices to un­der­served or vul­ner­a­ble pop­u­la­tions with­out re­gard for in­surance or in­come, and be af­fil­i­ated with a uni­ver­sity of an­other qual­i­fied health cen­ter.

Many of the ap­prox­i­mately 250 nurse-man­aged clin­ics that ex­ist to­day are af­fil­i­ated with lo­cal schools of nurs­ing, Gon­za­lez said.

Else­where in the law, Sec­tion 5316 sets up a $600,000 demon­stra­tion pro­gram to pro­vide one-year train­ing pro­grams for re­cently grad­u­ated nurse prac­ti­tion­ers who agree to work in nurse-man­aged health clin­ics. “The clar­ity and the em­pha­sis that’s in the leg­is­la­tion about health pro­mo­tion, dis­ease pre­ven­tion, main­tain­ing and max­i­miz­ing op­ti­mal health—this is huge for the nurs­ing pro­fes­sion,” said Bev­erly Malone, CEO of the Na­tional League for Nurs­ing, which rep­re­sents nurse fac­ulty and nurs­ing ed­u­ca­tion lead­ers. “Health­care is go­ing to have to move from the hos­pi­tal into the com­mu­nity.”

The law also adds $200 mil­lion over four years in fund­ing for a five-hos­pi­tal pi­lot pro­gram for Medi­care grad­u­ate nurs­ing ed­u­ca­tion, pay­ing hos­pi­tals with com­mu­ni­ty­based clin­ics to train ad­vanced prac­tice nurses in di­rect pa­tient care for Medi­care ben­e­fi­cia­ries. Sec­tion 5509 of the law says the grants will be based on how much growth is seen in ad­vanced prac­tice nurse-train­ing pro­grams, which teach nurses to pro­vide pri­mary care, pre­ven­tive care, tran­si­tional care and chronic care man­age­ment.

Nurses are also cel­e­brat­ing a pro­vi­sion that cre­ates an ex­pan­sive grant pro­gram to fund ma­ter­nal, in­fant and early child­hood visi­ta­tion pro­grams, in which nurses con­duct reg­u­lar home vis­its with low-in­come women on their first preg­nancy to coun­sel them on ma­ter­nal and child­hood health. Sup­port­ers say aca­demic stud­ies have shown that such pro­grams re­duce crim­i­nal jus­tice costs and give moms and kids bet­ter clin­i­cal out­comes.

“Over the years, we’ve been able to doc­u­ment that a woman of very lit­tle means who gets home vis­its has bet­ter out­comes, they are able to seek em­ploy­ment, their kids get bet­ter out­comes, there is less abuse and ne­glect,” said Su­san Hass­miller, the se­nior ad­viser for nurs­ing with the Robert Wood John­son Foun­da­tion, which has funded ma­ter­nal home-visit pro­grams for years. Sec­tion 2951 of the law ap­pro­pri­ates at least $1.5 bil­lion to the pro­gram be­tween 2010 and 2014.

But if de­mo­graphic fac­tors were al­ready con­verg­ing to cre­ate a huge nurs­ing short­age be­fore re­form even be­came law, where will all of the nurses for these new and ex­panded pro­grams come from?

The re­form law ad­dresses that need as well, nurs­ing ad­vo­cates say. Tucked away in the 906-page fi­nal leg­is­la­tion was the long-awaited com­plete reau­tho­riza­tion of Ti­tle VIII of the Pub­lic Health Ser­vice Act. Among other changes, the amped-up law pro­vides for greater tu­ition loans for nurses un­der Sec­tion 5202, and more op­por­tu­ni­ties for loan for­give­ness and schol­ar­ships for nurses who agree to work as fac­ulty in ac­cred­ited col­leges of nurs­ing for at least two years, in Sec­tion 5310.

Sec­tion 5311 ex­pands loan re­pay­ment pro­grams for higher ed­u­ca­tion tu­ition for nurses who be­come full-time fac­ulty at nurs­ing schools. The Amer­i­can As­so­ci­a­tion of Col­leges of Nurs­ing said the law re­moves the cap that for­merly limited grant­mak­ing to doc­toral of nurs­ing de­gree stu­dents to 10% of the over­all funds avail­able through the pro­gram.

Out­side of Ti­tle VIII, sev­eral dif­fer­ent sec­tions of the law reau­tho­rized and ex­panded nurse fund­ing for the Na­tional Health Ser­vice Corps, run by the Health Re­sources and Ser­vices Ad­min­is­tra­tion, in­clud­ing larger tu­ition re­pay­ment and schol­ar­ship pro­grams for nurses who agree to work in “health pro­fes­sional short­age ar­eas” for at least two years.

“We need to have a highly trained work­force to care for the pop­u­la­tion,” said Suzanne Begeny, di­rec­tor of govern­ment af­fairs for the Amer­i­can As­so­ci­a­tion of Col­leges of Nurs­ing. “To­day, if you are in the hos­pi­tal, you are darn sick. And we need to make sure the nurses have what they need to prac­tice in this new health­care sys­tem.”

Gon­za­lez: Move­ment to­ward pri­mary care noth­ing new.

Begeny: “To­day, if you are in the hos­pi­tal, you are darn sick.”

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