Health Care Delivery Models and Nursing Practice

Healthcare Legislation

The healthcare system is characterized by fundamental shifts from biomedical models and primary care to biopsychosocial models and community-based care, respectively. Laws have been mainly instrumental in supporting the restructuring of the system, including the roles of nurses. As the healthcare system evolves, so do the roles of nurses. The purpose of this paper is to analyze the actions taken to reform the U.S healthcare delivery system and their implication on nursing roles and responsibilities.

Medicaid Services Investment and Accountability Act of 2019

The Medicaid Services Investment and Accountability Act brought about the following changes (“Medicaid services investment and accountability act,” 2019):

  • Expanded Medicaid eligibility for patients receiving home care and community-based care.
  • Extended the qualification for Medicaid funding for individuals receiving healthcare from federally recognized community behavioral clinics
  • Allowed children with complex health conditions to choose a designated provider or a healthcare team to deliver health services at home.
  • Mandated drug manufacturers to disclose drug information – civil drug penalties would be applied to manufacturers who misclassify drugs.
  • Authorized the Centers for Medicare & Medicaid Services (CMS) to help states reduce institutionalized care by increasing funding to home care and community-based programs.

Implications of Legislation on Nursing Practice

The legislation promotes the use of an integrated healthcare delivery system. The current healthcare delivery to people with chronic condition can illustrate how the legislation has shaped current nursing practice. First, patients with chronic conditions often rely on collaboration between multidisciplinary teams to enhance effective disease management. Second, healthcare delivery among this population often occurs across several health settings, including hospitals, homes, and pharmacies. Unlike traditional approaches where the patients would choose providers from different healthcare settings, this statute allows patients to select an interdisciplinary team from a single hospital. This approach also facilitates seamless coordination of care and information exchange since all the physicians are under one umbrella organization. Retaining a patient under the aforementioned system promotes process efficiency, reduces costs, and the risks of rehospitalization (“Integrated care models,” 2016). It shifts the focus of nursing practice from hospitals to home and community-based and home settings. As the regulation changes the delivery of healthcare to community settings, so do the roles of nurses.

The Role and Responsibility of Nurses

In collaboration with other healthcare providers, nurses can design, implement, and evaluate the coordination and transition process. They can organize the components of care plans, assist patients in identifying healthcare options, document care, and mediate communication between individual members of the multidisciplinary team as well as between the team and patients and family. They can also lead and advocate for the dignified care of patients within the multidisciplinary team to ensure that patients’ needs are adequately addressed.

Pay for Performance (P4P) and Patient Outcomes

Operational reimbursement programs in the United States link compensation to quality measures to promote patient outcomes. The HCAHPs survey, for example, indemnifies hospitals based on their score ratings from patient experiences. In 2015, the CMS reported that it would either withhold 2% of compensations or reward top-performing healthcare settings based on their score ratings (“What is pay for performance,” 2018). Given that a considerable amount of a hospital’s income relies on these subjective experiences, healthcare facilities have to employ strategies to improve patient satisfaction and encounters. For instance, since the survey measures communication, staff responsiveness, pain management, timely care, and the setting’s environment, interventions to promote outcomes in these areas can be implemented to foster better patient outcomes.

Healthcare providers can also use CMS quality measures to improve health outcomes in their workplaces. Standardization is a mechanism or strategy that hospitals can utilize to achieve the same results in clinical practices. During quality improvement initiatives, healthcare facilities usually develop and implement approaches and behaviors based on the best evidence. Depending on the outcomes of the aforementioned projects, quality measures can either be improved upon or adopted as the standard practice at the hospital. With the replication of these procedures, evidence-based practices become systematic in the organization. Standardization increases the likelihood of achieving desirable health outcomes (Salmond & Echevarria, 2017). It can also result in capacity building, change in the facility’s culture, and learning.

Implications on Nursing Practice and Nurses’ Roles

The primary role of nurses is to coordinate and implement effective strategies in areas targeted by P4P efforts. Given that reimbursement programs give attention to care processes, nurses can align their practices with the policy requirements. For example, the P4P emphasizes the need to provide patients with adequate information and respond to their specific needs and preferences. Nurses, being the primary healthcare providers, are on the frontline of providing patients with this information. Therefore, the model promotes a nursing practice focused on patient-centered care by mandating providers to achieve the best outcomes in preestablished quality metrics.

Expectations and Responsibilities of Nursing Roles

Nurses work directly in units where the CMS collects data to measure a hospital’s performance. For example, the CMS gathers information on elements, including surgical wound infection and prevention, heart failure, pneumonia, and acute MI – myocardial infarction. Nurses can contribute to patient satisfaction in these specialties by conducting timely assessments, administering drugs and treatment plans, provide patients with prescription and discharge information. Nurse leaders can also address nursing interventions that aim to foster the impact of P4P on performance measures and the ability of nurses to contribute to the hospital’s efforts in achieving P4P outcomes.

Emerging Roles of Nurse Leaders and Managers

Advanced Practice Registered Nurse (APRN)

The APRN role has been one of the most impactful clinical changes brought by the ACA’s enactment. A recent systematic review demonstrated that APRNs could improve cost savings and patient outcomes for healthcare settings (Joseph & Huber, 2015). According to Joseph and Huber (2015), technological solutions to healthcare problems will require APRNs’ roles and contributions. The APRNs are trained and certified professionals whose duties include examining, diagnosing, ordering diagnostic tests, prescribing drugs, and managing patients’ health-related issues. For example, concerning value-based purchasing, APRNs can develop quality improvement systems to improve outcomes in each of the measured dimensions.

Clinical Nurse Leader (CNL)

CNLs mainly focus on improving healthcare delivery systems at the point of care. Their role was conceptualized by the American Association of Colleges of Nursing in response to the need for a well-defined leadership role that would improve healthcare quality. It was created to solve problems encountered during care coordination, such as fragmentation and care gaps that led to adverse health outcomes (Joseph & Huber, 2015). CNL improves patient outcomes and costs through advocacy, education, information management, care coordination, quality & patient safety, and outcome management. CNL responsibilities in the lateral integration of care are perhaps the most relevant in the emerging healthcare trends. Given that attention is shifting from primary care settings to community-based settings, CNL can optimize community-based care delivery (Aveling et al., 2017). A lateral integrator coordinates various functions to facilitate coordination and continuity of care across different health settings.

The Future of Nursing

Use of Technology

Technology will mediate clinical workflows and practices to promote health outcomes in clinical settings. Services such as telehealth and telemedicine will relatively increase with the use of social media and electronic devices. Tools such as Artificial intelligence systems and big data analytics will be used to plan and manage health data. Risling (2017) predicted that by 2025, the nursing curriculum would include education on data analytics and wearable technologies. Therefore, skills in nursing informatics or necessary technological skills will be a core skill in nursing.

Health Promoters

The role of nurses will shift from caregiving to health promoters in the future. Various statistics show that chronic conditions and the aging population will increase (Atella et al., 2018). Chronic diseases are characterized by acute pain, low quality of life, high healthcare costs, functional limitations, and the need for self-management education. About 80% of individuals aged 65 years and above have at least one chronic disorder (Atella et al., 2018). Nurses will play a critical role in alleviating or preventing the adverse outcomes associated with the condition. They will provide health education on self-management as well as education on disease prevention to pertinent communities to help address the complexities associated with these illnesses and aging.

Conclusion

Due to the emphasis on patient-centered care, programs such as P4P have been established to promote patient outcomes. The P4P program requires that nurses align their roles to accord closely to the policy’s requirements. The new healthcare system’s emphasis on community-based care increased the need for effective care coordination and an integrated healthcare delivery system. Consequently, roles such as the CNL and APRN were created to satisfy the needs of the system. Therefore, it can be surmised that the new healthcare structures have changed nurses’ roles in the healthcare system.

References

Atella, V., Piano Mortari, A., Kopinska, J., Belotti, F., Lapi, F., Cricelli, C., & Fontana, L. (2018). Aging Cell, 18(1), e12861. Web.

Aveling, E.-L., Martin, G., Herbert, G., & Armstrong, N. (2017). Social Science & Medicine, 173, 96–103. Web.

(2016). Web.

Joseph, L., & Huber, D. L. (2015). Journal of Healthcare Leadership, 7, 55–64. Web.

(2019). Web.

Risling, T. (2017). Nurse Education in Practice, 22, 89–92. Web.

Salmond, S. W., & Echevarria, M. (2017). Orthopaedic Nursing, 36(1), 12–25. Web.

What is pay for performance in healthcare? (2018). Web.

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