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The Role of the Registered Nurse in Ambulatory Care

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The Role of the Registered Nurse in Ambulatory Care American Academy of Ambulatory Care Nursing Position Paper: The Role of the Registered Nurse in Ambulatory Care N 2011 , the American Aca demy of Ambulatory factors, and access to care issues that impact the Care Nursing (AAACN) published the first-ever patient’s ability to adhere to a prescribed plan of care position statement regarding the role of the regis - and obtain needed services (Fraher, Spetz & Naylor, tered nurse (RN) in ambulatory care. Since that 2015; Lamb, 2014; Smolowitz et al., 2014). Itime, tre mendous changes have occurred in health Concurrently, health care is evolving rapidly to care, especially in ambulatory care. Healthcare meet the needs of an increasingly diverse and aging reform, the Afford able Care Act, the implementation population. At the same time healthcare costs are of care coordination as a strategy to improve health driving value-based reimbursement and innovative and prevent rehospitalization, and the transition from models of care. Ambulatory care RNs are well-pre - volume-based to value-based care have resulted in an pared to assume an expanded role in the design and increased focus on the ambulatory care setting as the delivery of high-quality care, defying traditional site of health care provision now and in the future. boundaries, and working in redefined interprofes - This position paper reflects the current state of ambu - sional relationships, expanded community partner - latory care and the crucial role of the RN as a care ships, and nontraditional healthcare settings. provider, care coordinator, and care partner. It also highlights potential role changes and adaptations for The Importance of the RN in Ambulatory Care the future. • RNs provide high-quality, evidence-based care across the lifespan to enhance patient safety, Background reduce adverse events, impact and improve Health care is in the midst of unprecedented patient satisfaction, support and promote optimal change. Improving the health of our nation will health status, track admissions and readmissions, require reframing our healthcare system from one that and manage costs within and among continually emphasizes acute, episodic, interventional care to one expanding, diverse, and complex populations. that engages patients and providers in health promo - Therefore, RNs are essential to the delivery of tion, disease prevention, and early intervention safe, high-quality care and should not be replaced (Bodenheimer, Bauer, Syer, & Olayiwola, 2015). As a by less skilled licensed, or unlicensed members result, this enhancement of the Role of the Registered of the healthcare team. Nurse in Ambulatory Care position statement • RNs are the team members best prepared to facil - (AAACN, 2011a) reflects current trends and changes itate the functioning of interprofessional teams to the RN role in response to the changing healthcare across the care continuum, coordinate care with environment. patients and their caregivers, and mitigate the Across the continuum of care, ambulatory care growing complexity of transitions in care. RNs work independently and collaboratively, partner - • RNs play a critical role in the delivery of tele - ing with patients, caregivers, providers, and other health services and virtual care. The development healthcare professionals in the design and provision of the art and science of telehealth nursing prac - of care in an ever-expanding array of settings. The tice has improved and expanded coordination of context of the ambulatory care environment is com - healthcare services, reduced patient risk, and plex, rapidly changing, and often difficult to navigate. contributed significantly to care management Care delivery design and implementation is directly models. influenced by social determinants, environmental AAACN’s Position Statement AMERICAN ACADEMY OF AMBULATORY CARE NURSING Creating a future that maximizes the role of RNs TASK FORCE MEMBERS: Susan M. Paschke, MSN, RN-BC, NEA- in an evolving healthcare environment will require BC, Chair; Stephanie Witwer, PhD, RN, NEA-BC, Co-Chair; Wanda sustained forward movement in nursing practice, C. Richards, PhD, MSM, MPA, BSN; Anne Jessie, DNP, RN; Linda Harden, MS, BSN, RN-BC; Kathleen Martinez, BSN, RN, CPN; education, research, and leadership. Therefore: Margaret F. Mastal, PhD, MSN, RN; Cynthia L. Murray, BN, RN-BC; Maureen T. Power, MPH, RN, LNCC; Mary Hines Vinson DNP, RN-BC. NOTE : This column is written by members of the American Academy of Ambulatory Care Nursing (AAACN) and edited by Kitty REVIEWERS: Ann Marie Matlock, DNP, RN, NE-BC; Rachel Start Shulman, MSN, RN-BC. For more information about the organiza - MSN, RN-BC; CDR David V. Thomas, MSN, RN; Nancy May, DNP, tion, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ MSN, RN-BC, NEA-BC; M. Elizabeth Greenberg, PhD, RN-BC, C- 08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 589- TNP. 7463; Email: [email protected]; Website: http://AAACN.org 1 American Academy of Ambulatory Care Nursing — Copyright © 2017 • RNs must be recognized and supported as leaders Centered Medical Home allowing ambulatory care in the transformation of health care in the ambu - personnel to function in newly expanded roles. New latory care setting (Institute of Medicine [IOM], ambulatory care roles for RNs have been formalized in 2010). They have expertise in the development, telehealth services (AAACN, 2011b) and in care coor - implementation, and sustainability of quality dination and transition management (AAACN, 2015). measures and clinical practice improvement. Today, “comprehensive health care includes care • RNs must practice at the top of their license, edu - coordination that is patient centered and focuses on cation, and expertise to affect quality and cost health promotion, disease prevention, smooth transi - through patient engagement, care coordination, tions between levels and types of care, health educa - enhanced teamwork, resource reduction, im - tion and the improved management of symptoms to proved access, and quality and outcome improve - avoid complication from disease and/or disability” ment. (AAACN, 2012, p. 235). The RN is the team member • Faculty and schools of nursing must design most qualified to coordinate the elements of care with undergraduate and graduate curricula to prepare patients and caregivers, as well as to facilitate the nurses for new roles in ambulatory care . functioning of interprofessional teams across the care • Health facilities must implement ambulatory care continuum. nurse residencies for new nurses and experienced nurses new to ambulatory care practice . Current State • Government and insurance carriers must recog - The U.S. healthcare system has undergone evolu - nize the impact on cost reduction an RN can pro - tion over many years; however, it is now at the vide under new reimbursement models which are precipice of radical change. Societal changes, emphasis linked to improved outcomes. on value, consumer engagement, technological • RNs must lead, participate in, and support per - advancement, and pressure to reduce costs are driving formance improvement activities designed to pro - redesign of every element of the care delivery system. mote and enhance quality and safety, improve Demographic trends. The U.S. Census Bureau efficiency in care delivery, and evaluate impact (Colby & Ortman, 2015) identifies broad demographic on patient outcomes. trends impacting healthcare delivery in the United • Researchers must build the science of ambulatory States. Rapid population growth, increasing diversity care nursing by engaging in the development of and number of foreign-born residents, and aging of new knowledge and innovation to build the evi - the population are expected to impact care delivery dence base needed to support quality practice. over the next several decades. These trends will chal - lenge the traditional healthcare system to seek new Evolution of Health Services in Ambulatory Care models of care that are flexible, proactive, accessible, Settings responsive, and cost effective. Ambulatory healthcare services have evolved sig - Increasing incidence and prevalence of chronic nificantly over recent decades. AAACN has consis - disease. In the United States, 117 million people have tently chronicled this dynamic history in major pub - one or more chronic conditions, with one in four adults lications (AAACN, 2010, 2011b, 2015, in press). De - having two or more (Ward, Schiller, & Goodman, 2014). tailed historical accounts include national and inter - Increasing numbers of chronic conditions lead to a pro - national efforts to redefine health and primary care, portional increase in cost of care. Medicare beneficiar - changes in the reimbursement of health care, and ies with five or more chronic conditions account for technological advances which revolutionized ambu - two-thirds of all healthcare expenditures (Anderson, latory care. New innovative types of ambulatory care 2010), leaving little for preventive care and health pro - settings have emerged including outpatient surgery motion for large numbers of Americans. In addition to centers, invasive diagnostic centers and infusion cen - managing their own medical and mental health condi - ters, among others. Sophisticated informatics systems tions, patients often face complex social needs, family have emerged which enable the documentation, eval - challenges, and difficulty navigating the healthcare uation, and dissemination of care and outcomes for system. These at-risk patients also have frequent hospi - patients,
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