AHIP Coverage(July/August 2007)
Operation Transformation
The nursing community is taking on a larger role in the national health care arena to effect change. American Academy of Nursing CEO Pat Ford-Roegner explains how.
By LaRonda Famodu
When Coverage spoke to Pat Ford-Roegner, CEO of the American Academy of Nursing (AAN), Washington, D.C., transforming the current health care system was definitely on her mind and on the minds of the academy’s 1,500 Fellows.
Selected from the best of the best, the AAN Fellows are key to putting the academy’s health care policies to work. Read on for their transformative ideas, and to learn how nurses are making a difference in quality of care, with uninsured and underinsured populations, and as partners with the health insurance industry.
Coverage: One of the organization’s strategic goals is to transform the health system into one that is designed to holistically treat patients. Can you elaborate and explain how you are working to achieve that goal?
Ford-Roegner: We’re very focused on this given the belief—the hope—that we’re ready as a country to tackle the transformation of our current health care system. This is a major part of our discussion internally and externally. And it’s part of the reason we launched our Raise the Voice! campaign: to have an opportunity from the nursing lens to talk about what we believe should happen in the transformation of the system to one that is much more personal, convenient, quality-based, community-based, and takes into account the life span of the individual.
So we launched our campaign and created an advisory board to amplify nurses’ message. It’s chaired by Donna Shalala and has many other incredible people on the advisory committee. We’re jumping into the fray because we really believe we have something significant to contribute to transforming the system. While we support the efforts for insurance coverage for all Americans, we don’t feel that is enough. It’s a first step, but we think the system itself needs a major overhaul to meet the current and future needs of the American public.
Coverage: So that was the impetus for the campaign—the transformation of the health care system?
Ford-Roegner: Right.
Coverage: What kind of response have you seen so far?
Ford-Roegner: We just collected and organized 15 concrete examples of nurses engaged in solutions to transforming the system. I visited one [of the 15] the other day—the 11th Street Primary Care Center in Philadelphia. It’s attached to Drexel University, and it’s been in existence for 11 years. There the leadership has put together a comprehensive center with everything from primary care to full dental care service to the integration of physical and mental health services. It’s a Medicaid-qualified center, and 40 percent of its population is uninsured working people with two jobs.
Their outcome data is quite good in terms of keeping people out of the hospital setting. And, in fact, it is showing good outcome data for such diseases as diabetes and obesity and a number of other issues along that line.
It’s a perfect example of one of the places we want to highlight. While there’s been a great deal of talk about what we can do to solve some of these issues, this is a prime example of a center that has been delivering this care, has a close relationship with the community, has a community board, is working with the Philadelphia Housing Authority—is really doing what we say needs to be done.
[Another example is] the work being done through Mary Naylor’s program. She happens to now be out of the University of Pennsylvania, and she’s working with Aetna on an advanced nurse practice model and with Kaiser Permanente System on a diversified [nursing model]—not only advanced nurses but an RN mixture—to deliver coordinated care for complex, chronic disease conditions.
It’s a model that’s been researched through clinical trials, and now they’ve expanded it. And it has the potential to offer innovative care and really prevent adverse effects, and that’s why Aetna and Kaiser Permanente were willing to get engaged with this research model.
“Edge runners” is the term we’re using to describe these individuals who are looking for or have begun or have been doing work like this for quite some time to demonstrate that we do have innovation out there that can be scaled up and modeled so we can solve this problem together as a nation. This is nursing rolling up its sleeves and saying, “We’re going to do this because this is what the population in this community said they need.”
Coverage: In what ways does AAN work to advance health policy?
Ford-Roegner: [The Fellows] are participating every day by appointments to a variety of advisory committees and boards such as MedPAC and the National Quality Forum Board and others in which they’re making individual contributions based on their expertise and skill set.
In addition, the academy itself—through our commissions, committees, and expert panels—uses the expertise of the Fellows to comment on a variety of national health care topics. Looking, for example, at the guidelines and priorities that we would like to see established around a particular issue, such as the reauthorization of the children’s health insurance program. That work comes out of a working group, one of which is our Expert Panel on Children and Adolescent Health. So we work through a system of expert committees and small groups that come together to tackle a national health policy issue.
Coverage: One group that faces several challenges is the underinsured. What are some innovations that nurses have put into practice to help this population?
Ford-Roegner: I mentioned the center in Philadelphia, but there is also a national organization of community nursing centers that were established in the 1980s. And they are all over the country. Some of them are also our edge runners. They have been looking at the needs of those populations in their communities and offering the preventive or primary care and integrated care services and working with the local public hospitals or voluntary hospitals. They’ve been doing that for years.
More recently, part of our effort is to really highlight those centers. For example, Good Samaritan Center in Kentucky started out with the homeless population, and the care was so good they were able to keep the homeless out of the hospital setting. And then they started to expand to a broader uninsured and underinsured population.
[Additionally,] retail clinics are popping up all over the country; they offer advanced nursing practice care. And in talking to the nurses who are running these convenient care/retail care clinics, [I’m finding that] often people are paying out of pocket and they’re underinsured or they have no insurance.
There’s a groundswell of different models that have been around and are now being highlighted that have been serving the uninsured and underinsured. I think it’s important for the country to take a good look at the variety of models out there [and ask], how do we scale them up?
Coverage: How is the nursing community addressing quality of care issues?
Ford-Roegner: What quality of care is all about is essentially that we want to improve health outcomes. We want to give the right person the right care with reduced adverse effects. It means lowering falls, lowering infections, lowering mortality rates. That’s what we all agree we want to do; the question is, how do we design a system that really does focus on improving outcomes, improving quality of care, being safe and efficient? How to do that is the challenge.
We are raising our questions and giving our suggestions on diverse quality performance measures and how we come to consensus on those. Also how we recognize the contributions of various professions, not only nursing. I think the measurements have been heavily physician-oriented up to this point, and there are many of us participating in this transformation. We need nutritionists, we need social workers and nurses—a variety of people who make a difference in our system.
Coverage: What are some new opportunities for nurses working in programs with insurers?
Ford-Roegner: We talked a little bit about the quality assurance issues. Nurses have moved into that arena. Nurses are looking at these new models of coordination of care. And there are a number of ways they’re getting engaged in the insurance industry itself, for instance, looking at new packages of benefits.
Two more of our edge runners, two advanced nurse practitioners, were behind the concept of the Evercare model of innovation, which is a part of United Healthcare. It is both a community- and institutional-based benefit that heavily uses advanced nurse practitioners for individual case coordination for the elderly or even those over 50 who need coordination of chronic disease care.
So they’re everywhere from creating concepts that then become benefits packages to involvement in quality assurance and design of plans.
Coverage: As a follow-on question, what opportunities do you see for collaboration with the insurer community?
Ford-Roegner: I’d encourage the insurer community to take a look at its boards of directors and make sure every one of them has a nurse expert on board to bring richness to the table. Another way I would hope we could work together, of course, is on this transformation of the system.
Take the movement toward personalized health records, for example. One AAN Fellow, Patti Brennan at Michigan University School of Nursing, is director of the Robert Wood Johnson Foundation’s Project Health Design, which is doing the work on personalized health records and how they can be much more than a tool for recording personalized data; [they can be] a tool for wellness and integration of care. So I think there are some incredible opportunities. The other piece of it, though, is recognizing that there are nurse innovations that have been tried out and can, in fact, prevent adverse effects and thereby reduce future costs. So I think there would be natural synergy if we could be supportive of each other.
Coverage: Let’s talk about AAN’s Workforce Commission. How does the commission help alleviate the burden created by the nursing shortage?
Ford-Roegner: The work that’s being done at the moment is looking at how we can reduce the demands on the current nursing workforce. For example, how do we get technology to improve the workflow for the health care staff—particularly nurses—so they can do what we expect them to do and deliver high-quality care to the patient?
We have done about 26 drill downs in acute-care hospital settings with a diverse health care staff and technology leaders, architects, and others to essentially look at how we make the structure of hospitals better. We are looking at everything from the design of the floor plans to systems. The research coming out of these studies is going to really show the amount of time taken away from the delivery of direct care to move around, to find other staff, or to find equipment, and so forth.
[Another issue is the] inoperability of technology. We’ve talked to some nurses who end up keeping written notes as well as computerized notes because of problems with their systems. And if you’re doing that twice, it’s pulling you away from the direct patient care.
So our work is really looking at what are the demands and how do we reduce the demands. AAN’s current president, Linda Burnes Bolton, chief nursing officer at Cedar Sinai Hospital in Los Angeles, talks about making it a “lean day” so that you are able to come in, look at your plan for your patients, and get the work done. Not, does the equipment on the wall work? Nurses often say they’ve got their pockets jammed with various equipment, the blood pressure cuffs and so on, because the ones on the wall don’t work 50 percent of the time. All of that is pulling away from patient care and frustrating practitioners. They have many opportunities to go out and find work in other places. We are losing them from direct care, and we don’t want that to continue.
LaRonda Famodu is a freelance writer and editor based in Hillsboro, Oregon.
