How can nurses assist in effectively managing patient care within an evolving health care system?

Massachusetts General Hospital is known for medical innovations such as the first public demonstration of surgical anesthesia and the first replantation of a severed arm.

Today, the venerable Boston hospital is testing out another innovation, but this time it’s in the field of nursing. When a patient arrives at Massachusetts General Hospital (MGH) now, he or she is assigned an attending registered nurse (ARN) for the duration of the hospital stay and after discharge. The ARN builds a relationship with the patient and his or her caregivers, and ensures that all members of the patient’s health care team follow a shared care plan. Unlike other RNs, ARNs are designed to promote continuity of care, ideally with a five-day, eight-hour work schedule.

“The role is designed to be a constant throughout the patient experience,” says Jeffrey Adams, PhD, RN, director of the Center for Innovations in Care Delivery at MGH and a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2014-2017). “The person the patient sees every day is available ahead of admissions and post-discharge. This is different than anything we’ve seen before. We evaluate this work closely and we know ARNs have significantly contributed to improved quality and patient satisfaction.  

The ARN is just one of the many new roles for nurses in a changing health care system. These new roles are empowering nurses to play a greater role in improving patient experiences and population health and lowering costs. Nurses in new roles are doing that by reducing unnecessary and costly hospital readmissions and preventable medical errors, providing more affordable, more convenient, and more patient-centered primary care in community-based settings, and more.

Nurses today are playing new roles in coordinating care from multiple providers, managing caseloads of patients with intense care needs, and helping patients transition out of hospitals and into the home or other settings. They are working as “health coaches” and in other ways to prevent illness and promote wellness. And they are charting new paths in emerging fields like telehealth, informatics, and genetics and genomics, and as scientists and leaders in society.

Traditional RNs and advanced practice registered nurses (APRNs), meanwhile, are playing expanded roles as the health care system evolves to meet new needs. Once viewed as subservient and subordinate, nurses are now serving as full and essential partners on interdisciplinary health care teams. APRNs are opening nurse-led primary care clinics and operating independently—without physician supervision—in a growing number of states and in new settings, such as at retail pharmacies and “big-box” stores like CVS, Walgreens, and Target.

Clear Benefits Include Better Clinical Performance and Patient Experience

Ed Wagner, MD, MPH, has observed this shift as co-director of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), an RWJF-supported program. During 2012 and 2013, he and his colleagues visited 30 high-functioning primary care practices to learn about innovative staffing arrangements that maximize the contributions of nurses and other staff. During the visits, the LEAP team noticed that nurses are increasingly providing more direct, face-to-face care in independent nurse visits or shared visits with providers.

The benefits, he said, are clear. “The practices that are engaging nurses in these new, expanded ways are showing better clinical performance and better patient experience” scores, he noted. For patients, “it means better care, no question.”

LEAP’s findings echo a 2010 report by the Institute of Medicine on the future of nursing that said nurses must play new and expanded roles to improve access to quality care and to lower costs. “Nurses are well positioned to help meet the evolving needs of the health care system,” the report states. “They have vital roles to play in achieving patient-centered care; strengthening primary care services; delivering more care in the community; and providing seamless, coordinated care. They also can take on reconceptualized roles as health care coaches and system innovators. In all of these ways, nurses can contribute to a reformed health care system that provides safe, patient-centered, accessible, affordable care.”

New Payment Systems Support New Roles for Nurses

New laws and policies are enabling nurses do to just that, according to Ellen-Marie Whelan, PhD, CRNP, FAAN, senior advisor to the Centers for Medicare and Medicaid (CMS) Innovation Center. “Health reform and changes in the Affordable Care Act create amazing opportunities for nurses, in large part because of the way we’re paying differently for health care,” she said.

The government is moving away from fee-for-service systems and toward paying for improved outcomes, which create opportunities for nurses, said Whelan, an RWJF Executive Nurse Fellow (2012-2015) and an alumna of the RWJF Health Policy Fellows program (2003-2004). Payment changes, based in part on improved patient outcomes—such as with shared savings in accountable care organizations and bundled payments—will allow nursing contributions to be maximized, she noted. Medicare coverage for wellness and behavioral telehealth visits and care coordination for patients with multiple chronic conditions are services often led by nurses.

“We are going to see increased accountability and responsibility for nurses in the general areas of transitional care and care coordination,” said Mary Naylor, PhD, RN, FAAN, national program director for the RWJF-sponsored Interdisciplinary Nursing Quality Research Initiative and creator of a model in which nurses lead care transitions across settings.

“Nurses,” she continued, “will not only have enhanced responsibility and accountability in traditional settings, such as patients’ homes and community-based clinics, but increasingly have roles that enable them to move across health care settings such as from hospitals to patients’ homes. Evidence reveals that such role changes will better align with the care experience and needs of patients and their families, and result in improved outcomes.”

“Some people call this the de-linking of the hospital nurse,” Naylor said. “Rather than being setting-bound, nurses will work door-to-door. These aren’t just ideas, this is happening now.”

And that’s just the beginning, Adams predicted. “I am confident we have not yet seen the full spectrum of the innovative roles that nurses will develop and fulfill. As health care incrementally transforms to embody a Culture of Health, there will certainly be increased opportunities to ... place nurses at the center of conversations, development, and implementation of new roles and new models of care.”

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