Susan C. Reinhard, PhD, RN, FAAN, Senior Vice President, AARP Public Policy Institute, USA, spoke to a gathering of 200 nurse educators, leaders and professionals at “Connecting the Dots: Gerontology Nursing Education, and Clinical Simulation” on April 2, 2009. The conference is hosted by The University of North Carolina at Chapel Hill School of Nursing and Flinders University, Adelaide, South Australia.
Reinhard’s talk is titled “Through the Looking Glass” and the notetaker is Norma Hawthorne, director of advancement, UNC Chapel Hill School of Nursing. Her remarks follow.
Professional opportunities for the specialty of geriatric nursing is decreasing worldwide. Yet, regardless of the healthcare setting, more nurses are delivering healthcare to older persons. This conference is important because it addresses ways to equip the nursing workforce to meet the health care needs of aging patients.
This conference represents the best of nursing for being proactive and collaborating together to achieve a goal. We applaud this shared vision between The University of North Carolina at Chapel Hill and Flinders University to bring this conference to you.
There are many opportunities for nurses with geriatric competence, especially as we prepare the new nursing workforce. Health care reform in the U.S. must focus on how nurses can take the lead in health care reform especially in addressing chronic illness at all ages and the competencies related to family care giving. Emphasis will move away from acute care to family centered care, and this is what we need to change health care costs and delivery.
How we provide hospital care is an indicator for changing the trajectory moment – We must pause to ask: How you can work with the individual, family, and people on the care giving team to transition between dealing with chronic and long-term care needs. This will help us change the way we are thinking and paying about care.
In the future, we will no longer pay for hospital care. We will pay for episodes or bundles of care – more like a DRG across settings. Then, we have to think about people across settings that challenges how we are educating. The health care system the way it is structured now could not be any worse for what we need.
The educational system parallels this broken delivery system. So, we need to educate people for a visionary system. The U.S. is not alone, but other countries around the world are doing somewhat better although this is an international problem.
Changing the way nurses are educated is a challenge for faculty, funders, and regulators. Nurses have a social mandate to WORK WITH PEOPLE and families in the context of their lives. This is the uniqueness of nursing.
Using simulators in teaching is critical. How do we build in simulations that involve the whole care giving unit – the patient, the family, and a multitude of caregivers.
Regarding health care reform in the U.S., we learned many lessons from the failure 15 years ago at national level. What can we do now? Costs are higher now. Health care is not sustainable and must change. Costs are not related to quality. Employer sponsored coverage is eroding. Retirees worry. Here in North Carolina there are high unemployment rates and many have no insurance. This is a nationwide issue. Primary care is in crisis, and this is a recent phenomenon. We need to prevent problems from occurring now and look at state models like the one in Massachusetts for state health care reform, which focuses on coverage first and delivery systems and costs later. Once you have coverage, more people seek preventative care and need advance practice nurses. This is no longer a theory. We need more highly skilled and primary care givers, including geriatric nurses.
Quality has become impossible to measure. Geographic variation is immense—there are variations in costs and quality around the country. Variation is causing a 30% oversupply in care – people getting too much care, too many tests, too much surgery. There is extra money in the system, but it’s hard to identify and extract out where it can be reallocated. This is the crux of health care delivery system reform. Before, managed care was to deal with cost and this blew up. Focus now must be on nurse led interventions in transition between hospital and home – the transition of care. This will be the focus of how we reform.
The critical element is having a nurse within an interdisciplinary team, working on medical, social, counseling issues.
Another model discussed is the “medical home” or “health care home” that is included in the state statute in Minnesota. But our research tells us that consumers don’t like this because they don’t want a “nursing home.” They want care in their own home and within their family context. The original “medical home” notion was created by pediatricians around a coordination of care concept for children with developmental disabilities. There is an opportunity here because there is no evidence, no research about how this might work for health care at all stages of the life cycle. As nurses and caregivers, we must lead and deal with chronic care and put in evidence-based interventions.
A big issue , too, is physician payment reform. Will this affect payment for advance practice nurses? We must move to “blended reimbursement” and pay for performance. We must talk about value, not cost and quality. We must talk about how nurses bring value by increasing quality. Cost is not as much an issue although nurses bring down cost. There is no research on this either. The more physicians you have, the more surgeons you have … then what? Where do nurses fit in?
White House Forum on Health Care Reform, like the one held in North Carolina earlier this week is important in the change process. There is tension between federal and state control. In most countries that have well- developed health care system, federalism is pretty high. In our system, states want control and that is part of our history and culture,. But to me, the big question is, Why we have 50 different state Medicaid programs. We need universal systems of care.
There are overarching policy issues. How do we improve value (delivery system reform)? We don’t know how to include everyone. There is a lot of energy around health prevention and promotion, but the research results show we don’t know how to change behavior.
We need $1.5 trillion over next 10 years to create a new health care model. Do we want a public plan to compete with private plans? How do we keep long-term care, which will be an on-going need, in the mix? We must talk about chronic care. Unfortunately, the worse our economy gets, the more likely we will get health care reform, because health care cost is a big driver to our economy. We can’t afford another failure and we can’t worry about making it perfect.
Chronic diseases impact people of all ages. Twenty-five percent of the population in 30 states have obesity prevalence. Our children are at risk for good health and there may not be enough family caregivers for them. Most people are working and their issues are covered by whatever insurance system we employ. Older Americans have more chronic conditions. More than half of people on Medicare have five or more conditions, up 30 percent from 10 years ago. If a person has five or more chronic conditions, this results in $16,000 per year per person in cost. People cannot save if they are paying for high health care costs, and 22 percent of the total health care cost in this country is for one percent of the people.
Rough Crossings and Communication Breakdowns
Research at AARP shows that one in four caregivers say transitions are not well coordinated— referred to as “rough crossings.” Communication is problematic. Twenty percent of patients say providers didn’t communicate well with each other and gave them conflicting information. Quality is suffering from this and there are more medical errors and unnecessary tests. After receiving advice from physicians and advance practice nurses, 27 percent of patients did not do what was recommended because they didn’t agree with the advice. Pain is a big issue, many don’t remember what their clinicians told them, and others feel abandoned. Caregivers are stuck because they are the ones who need to find resources, manage relatives’ expectations, and don’t have enough time. “You have to be tough, you have to be an advocate,” says 82 year old caregiver. Many say the ball dropped after discharge, and they didn’t know what follow-up services were needed.
People who were not engaged were more likely to report that their healthcare got worse.
Caregivers are giving $375 billion of free care. Their services delay institutionalization but their own economic well being and personal health are compromised. Caregivers are asking for more support and need to be recognized as a member of the health care team. The nurses’ role is bring patients and caregivers into a learning laboratory, and to educate as part of interdisciplinary teams.
The Center to Champion Nursing in America, an AARP and RWJF partnership, was formed to focus on faculty. Over 100,000 qualified students are being turned away from nursing programs each year. Half of all faculty will be retiring in the next 10 years. We face a real crisis. Policy makers hear there is a shortage, but they think the shortage is ending because there are no vacancies because the economy has created a lack of new positions. They don’t know about the faculty shortage and the need to reduce demand on nurses. As we create environments for problem solving, we need to include organizations into the discussion that are not nursing centric. We need to expand and lift the voice of nurses and bring in corporations that are also stakeholders.
Half of nurses do not work in hospitals. A recent poll showed that 56 percent of nurses work outside of hospitals. If we decrease the length of patient stays, this will only increase. We need to tell the story that nurses work everywhere. They focus on people, not on settings. Advance practice nurses are highly educated and have the skills to deal with complex situations. Regardless of their specific credential and certifications, nurses are highly educated and capable of managing chronic and acute care, and leading health care teams. But there is a disconnect. The public thinks nurses are trained on the job.
Another key issue is that 60 percent of our nurses are educated at the Associate Degree level, and less than 20 percent go beyond to earn the baccalaureate degree. We cannot have a preponderance of our profession trained at the AD level because we need people with doctoral and masters degrees to teach, and there are not enough faculty in the pipeline to satisfy society’s needs.
Reinhard is a fervent believer in embracing the Institute of Medicine report for retooling for the aging of America. We must, she says, create more opportunities to delegate responsibilities to unlicensed assistant personnel so that nurses can be in charge, but delegate and supervise as we ensure that everything is being done within the legal scope of practice.