Posted on | January 26, 2011 | 5 Comments
Ten days ago, my wife and I were blessed with the arrival of our 8th and 9th grandchildren – two little girls, Charlotte and Luca. We were also introduced for the first time, as health consumers, to the Neonatal Intensive Care Unit (NICU). The girls came early, at 34 weeks, and are working their way up to their due date. They are doing great, but it’s not easy on them or their parents or the care teams committed to their well being.
Viewing them from my grandparent bias, the Connecticut Childrens Hospital Center NICU team at Hartford Hospital is doing a great job, balancing high tech with high touch, providing wisdom and reassurance, inclusion and training to the girls’ parents who are clearly part of the team. Viewing it all from my bias as a former surgeon, hospital administrator and health policy analyst, I am equally impressed but not surprised.
When people claim that “America has the best health care”, they’re talking about these kind of complex care settings within our elite teaching hospitals. Specifically they are referencing groups of highly skilled doctors and nurses, committed to their patents and to each other, armed with experience, judgment and technology to – collectively – heal and provide health, and keep us whole in the process. It’s really a holy thing to observe, and reinforces why I chose this life way back in 1965 as a 17 year old college student.
Translating this type of in-patient care, and specifically these models of nurse – physician cooperative care teams into the outpatient setting, however, has remained problematic. Inside they are professional collaborators; outside they are often business competitors.
Ground zero in the battle is Nursing scope of practice. Sixteen states have liberalized scope of practice for advanced practice nurses, but most have not.(1) The Institute of Medicine and multiple studies say nurses are up to the task and the patients will benefit.(2,3) But major medical organizations like the American Medical Association, the American Osteopathic Association, the American Academy of Pediatrics, and the American Academy of Family Physicians disagree, despite the growing body of evidence that supports the move. (1)
In this week’s lead article in the New England Journal of Medicine, the authors emphasize the urgency to act now. They say, “This is a critical time to support an expanded, standardized scope of practice for nurses. Economic forces, demographics, the gap between supply and demand, and the promised expansion of care necessitate changes in primary care delivery. A growing shortage of primary care providers seems to ensure that nurses will ultimately be required to practice to their fullest capacity. Fighting the expansion of nurse practitioners scope of practice is no longer a defensible strategy.” (1)
Furthermore they say “Effective implementation of new delivery models, such as medical homes and accountable care organizations, which would provide chronic disease management and transitional care, requires the establishment of interdisciplinary teams in which nurses provide a range of services, from case management to health and illness management.” (1)
It is on this last point that I would like to focus your attention – creating the kinds of high performance teams as I witnessed the past 10 days in our granddaughters’ NICU, but in outpatient settings. My message to the House of Medicine: Step one in delivering excellent home –centered health care is to eliminate the distraction of a continued protracted fight with the Nursing Profession over scope of practice. Step two is to create elite outpatient teams focused on patients, families, and community. Step three is active inclusion of home caregivers in the team as both providers and consumers of care. Step four is to embrace modern technology to accomplish 24/7 connectivity. (4)
This approach is being utilized by a number of systems including the VA, Geisinger Health System and Kaiser-Permanente with good results. With 32 million new health care consumers gaining coverage with the Affordable Care Act, it’s time for all of us – doctors and nurses – to act like professionals. (1)
For Health Commentary, I’m Mike Magee
- Furman JA et al. Broadening the scope of nursing practive. NEJM 364:3, 2011, 193-196.
- Laurant M et al. Substitution of doctors by nurses in primary care. Cochrane Database System Review 2005;2:CD001271
- Institute of Medicine. The future of nursing:leading change, advancing health. Washington, DC:National Academies Press, 2010.
- Magee M. Home-Centered Health Care. 2007 Spencer Books, NY, NY. www.spencerbooks.com.