Kathy Duckett, RN, BSN, is the Director of Clinical Programs at Partners Healthcare at Home in Waltham, Massachusetts.
The author declares no conflicts of interest.
Address for correspondence: Kathy Duckett, RN, BSN, 281 Winter St., Suite 240, Waltham, MA 02451 (firstname.lastname@example.org).
The Institute of Medicine's (IOM, 2010) report, “The Future of Nursing: Leading Change, Advancing Health,” brought the conversation on where nursing should fit into the new healthcare delivery system into the national spotlight. This seminal report clearly articulates the potential roles for nurses in the redesigned healthcare system. It also clearly articulates the challenges that the new roles will present to the current nursing profession and the changes required by nurses and the nursing profession to meet those challenges.
In 1867, Florence Nightingale was radical in thinking that by the year 2000, hospitals would be abolished and the future of nursing care would be in the home. Today, more than ever before, home healthcare and home healthcare nursing is being seen as an essential part of the new healthcare delivery landscape. It is an exciting time to be in home healthcare, and, as someone who has spent more than 20 years of her career in the field of home healthcare, I am thrilled that home care is finally being seen as the solution instead of as “that thing you do for patients in their home.” Accountable care organizations (ACOs), person-centered medical homes (PCMHs), care transitions, and bundled-payment models all require a home healthcare component if they are going to meet the Centers for Medicare & Medicaid Services' triple aims of improved patient healthcare, improved population healthcare, and reduced costs. However, many times in discussions around ACOs, PCMHs, and bundled-payment care organizations, the “home care” option does not include the local home healthcare agency as a partner. I believe we are up to the challenge to ensure that when “home care” is discussed, the home healthcare agency is the solution. To embrace the new roles and opportunities provided to home health agencies, we need to embrace the fundamental transformation of the nursing profession as described in the IOM report key messages of:
1. Transforming practice: Nurses should practice to the full extent of their education and training.
2. Transforming education: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
3. Transforming leadership: Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States.
4. Meeting the need for better data on the healthcare workforce: Effective workforce planning and policymaking require better data collection and an improved information infrastructure. (IOM, 2010)
I believe that we can and must transform the way we represent “that thing we do for patients” to our nursing colleagues, the medical profession, and to the wider community. But first we have to transform the way we see ourselves and the unique contributions that we make as home healthcare nurses. Recent articles on home healthcare nursing recruitment and retention have focused on internal organizational changes that have an impact on improving recruitment and retention, but the focus is on what nurses value in their current work environments (Flynn, 2005; Smith-Stoner & Markley, 2007). If we are to be relevant in the future, we need to focus on transforming ourselves for the new roles and opportunities that will be available to us both as individual home healthcare nurses and as home health organizations. The IOM report provides us the blueprint for achieving that transformation individually and organizationally.
During the 1990s, as we moved from per-visit reimbursement for home care nursing services to interim payment system and prospective payment system (Medicare Part A) 60-day episodic global payments, our nursing interventions became more task-oriented and less holistic and care coordination-oriented. After the 1997 Balanced Budget Act changed the way home care was reimbursed, the average length of stay in home care decreased from a median of 60 days to a median of 44 days (Murkofsky et al., 2003). We were encouraged to “get in, get it done, and get out.” We were no longer practicing to the “full extent of our education and training.” With the focus on chronic care management as a necessity for cost containment and the unique position of home healthcare as a cost-effective provider of chronic care management through programs such as the Integrated Chronic Care Management model (Suter et al., 2008), home healthcare nurses are once again required to use the full extent of our education and training. The IOM report states “... the care in the future is likely to shift from hospital to the community setting. ... Nurses must create, serve in, and disseminate reconceptualized roles to bridge whatever gaps remain between coverage and access to care. More must become health coaches, care coordinators, informaticians ... such a transformation would return the nursing profession to its roots in the public health movement of the early 20th century” (2010). I read this and think that they are really describing all the things that we, as home care nurses, used to do for our patients and are now being asked to do again.
The challenge I find as I implement the Integrated Chronic Care Management program at my own organization is that we are reaping what we have sown in terms of our staff's ability to transition from task-oriented care delivery to patient-centered care management. For some staff, the transition back to the “roots in the public health movement of the early 20th century” (IOM, 2010) has been difficult because they came to home healthcare in the “get it done” 1990s, whereas for other staff, the reaction has been “at last we are going back to doing real home healthcare nursing.” Home healthcare nurses are going to be required to use all the skills of our education and training for patient care and leadership in home care is going to be held accountable to require nothing less than the best we have to offer as nurses. This will require that organizations redefine nursing productivity. Productivity needs to be defined by outcomes instead of the number of visits per day. I have been in home care nursing for over 20 years, and the productivity standards for nurses have always been 6 visits/day (NAHC, 2009). According to National Association of Home Care and Hospice the average registered nurse productivity is 4.96 (Medicare.gov, 2011). We have been trying to quantify productivity based on visit averages for years, but we still are not there yet. Although home health agencies have been missing their “productivity” expectations for years, CMS Home Health Compare scores have consistently improved—except in the area of rehospitalization (Fazzi Associates, 2011). As organizations change their thinking from productivity (i.e., how many visits are made in a day) to the outcome of the care provided to the patient, nurses will be held increasingly accountable for the quality of care they provide. The principles of nursing (assess, plan, intervene, evaluate) we were taught as part of our education and training will be the basis for evaluation of our effectiveness in care provisioning. We will transform the current practice of home healthcare nursing when we are focusing on using the education and training we received as nurses to function at the top of our license and provide carefully planned, patient goal directed, outcome-driven care at each patient visit.
The IOM report (2010) emphasizes the need to have nurses begin their careers at the baccalaureate level of nursing and recommends that the number of nurses who hold a baccalaureate degree increase from 50% to 80% by 2020. Hospital studies have shown a decrease in patient mortality with the use of BSN-level staff and the American Association of Colleges of Nursing's (AACN) position since 2000 has been that the BSN is the most appropriate entry-level point for professional nurses because of the “greater orientation to community-based primary health care, and an emphasis on health promotion, maintenance and cost-effective coordinated care,” and several countries require BSN level nursing degrees as the minimum entry level for home care agencies (AACN, 2000). Career ladders for home healthcare nurses including increased pay for increased education have not been a hallmark of our profession. Few home care agencies reward staff for increased educational levels or have policies related to agency support for pursuit of higher education or advanced training as part of a career ladder in home care. If home healthcare organizations expect to transform the practice of nursing, then incentives for pursuing higher levels of education and/or training will need to be provided at the field nurse level as well as at the administrative level.
The IOM report states: “Strong leadership is critical if the vision of a transformed healthcare system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the healthcare system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions” (IOM, 2010). Expecting to be considered a full partner in the healthcare team is where we in home care start the discussion because of our training as home healthcare field staff. The best home healthcare nurses establish partnering relationships with patients, physicians, and other members of the multidisciplinary team as part of their day-to-day functioning.
Organizationally home health agencies have been inconsistent in planned, proactive training for leadership roles. If we are to position ourselves as equal partners in healthcare reform, we must do a better job of training the younger generation of staff nurses to assume leadership roles in home care in a purposeful manner through formal leadership training, ongoing planned mentoring, and opportunities to grow in the organization. Many leadership quotes revolve around the fact that you cannot “make” someone a leader. That may be true, but the opportunity to learn how to be a leader requires training, mentoring, and a safe place to fail. Home health agencies must assume leadership roles on a State and National level if we are going to be able to guide policy and practice to promote quality driven, safe care to patients at home and in the community. Home health nursing leaders need to provide opportunities in their agencies to teach the skills and competencies to develop leaders for the home healthcare profession, the nursing profession, and across the healthcare spectrum.
Meeting the Need for Better Data on the Healthcare Workforce
The work the government will do in this area will have a tremendous impact on home health agencies. As better data is collected to determine the number of Americans needing home care services, a determination of the professional nursing home healthcare workforce needed to meet the demand should send a clear message to Congress that cutting funding to home care is the wrong way to ensure the workforce is available to meet the healthcare demand.
The National Health Workforce Commission was formed under the Patient Protection and Affordable Care Act (ACA) to “[develop] and [commission] evaluations of education and training activities to determine whether the demand for healthcare workers is being met,” and to “[identify] barriers to improved coordination at the Federal, State, and local levels and recommend ways to address such barriers” (GAO.gov, 2010). The ACA also authorized a National Center for Workforce Analysis, as well as state and regional centers. Home health organizations and nurses must be vigilant in working with their state organizations to ensure that home healthcare requirements are part of any healthcare work force discussion.
Florence Nightingale was right; “the ultimate destination is the nursing of the sick in their own homes” (Maindonald & Richardson, 2004). Home healthcare nursing is being increasingly viewed as the method to control healthcare costs while providing safe, high-quality care. Is home care nursing up to the challenge? Absolutely. Is every home care agency and every home care nurse ready today to provide the care being envisioned by healthcare reform? Absolutely not. But the IOM report gives us a blueprint. We need to have the will to follow it. The future of nursing in home healthcare is now. How can we not take the opportunity to be healthcare leaders?
Flynn, L. (2005). The importance of work environment: Evidence-based strategies for enhancing nurse retention. Home Healthcare Nurse, 23
GAO.gov. (2010). National Health Care Workforce Commission, Subtitle B: Innovations in the health care workforce, Section 5101, National Healthcare Workforce Commission
. Retrieved from http://www.gao.gov/about/hcac/nat_hcwc.html
Murkofsky, R. L., Phillips, R.S., McCarthey, E. P., Davis, R. B., & Hamel, M. B. (2003). Length of stay in home care before and after the 1997 Balanced Budget Act, JAMA, 289
Smith-Stoner, M., & Markley, J. (2007). Recruitment and retention: Tips for retaining nurses, one state's experience. Home Healthcare Nurse, 25
Suter, P., Hennessey, B., Harrison, G., Fagan, M., Norman, B., & Suter, W. N. (2008). Home-based chronic care: An expanded integrative model for home health professionals. Home Healthcare Nurse, 26
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