Increasing Primary Care Capacity Through Academic Preparation and Effective Utilization of Registered Nurses in Team-Based Delivery PREPARED BY Judith G. Berg, MS, RN, FACHE Former President and Chief Executive Officer Carolyn Orlowski, MSN, RN Program Director AUGUST 2019 ACKNOWLEDGMENTS Contents This project was conducted with the support and col- 1 Introduction: laboration of the California Health Care Foundation, Escalating Need for Primary Care which sponsored the work, and consultative assistance of an advisory team of academic and practice leaders 2 Trends and Driving Forces across California. (See Appendix A.) The knowledge, Value-Based Payment and Care vision, professional commitment to primary care, and diverse experience and expertise of the advisory The RN Workforce team members contributed significantly to the project Assumptions Underlying design, key areas for exploration, and the synthesis of This Project findings in developing actionable recommendations. 3 Summary of Findings Their leadership representing key statewide organiza- tions also strengthened important connections with 4 Recommendations for Change: leaders, organizations, and communities in California, Five Key Domains ensuring that the findings would be representative, Domain 1: Transforming the Practice Environment to relevant, and evidence based. Effectively Utilize RNs In particular, the project team is grateful for the time Domain 2: Supporting the Primary Care Career and contributions that Laurie Bauer, MPH, PhD(c), RN, Development of RNs from the UC San Francisco School of Nursing, pro- Domain 3: Educating Nursing Students in Primary Care vided in supporting the development and testing of Domain 4: Developing Nursing Program Faculty with the survey questions, assisting with facilitation of focus Primary Care Expertise groups, and analyzing key findings. Domain 5: Increasing Opportunities for Interprofessional Education and Development of Collaborative Team- The project team also acknowledges the importance Based Practice Models of many primary care leaders, nurses working in these settings, and academic nursing program leaders, who 13 Conclusions: dedicated time to participate in the various surveys Timely and Reachable Opportunities and focus group sessions; they provided valued infor- mation, shared their experiences, and provided ideas 14 Appendices to strengthen the preparation and development of A. Advisory Team the future primary care nursing workforce. B. Recommendations and Strategies Sorted by Stakeholder Group 20 Endnotes HealthImpact 663 13th Street, Suite 300 Oakland, CA 94612 www.healthimpact.org Suggested citation: Increasing Primary Care Capacity Through Academic Preparation and Effective Utilization of Registered Nurses in Team-Based Delivery (Oakland, CA: HealthImpact, 2019). Introduction: Escalating “ My role is unique in that I work with Need for Primary Care people who may have no one else in their California will face a shortage of 4,100 primary care providers in the next 10 years, according to a 2019 lives, often being the primary liaison report by the California Future Health Workforce when they interact with different health Commission.1 At the same time, the demand for pri- mary care services will continue to accelerate due care systems. ” to the state’s growing and aging population, as well — PRIMARY CARE RN as payment models requiring value-based care and strong patient-centered focus on health maintenance and illness prevention. The trends point to an urgent need to expand and About This Project more efficiently deploy California’s primary care work- An advisory team of experts in primary care, nursing, force. Effective utilization of registered nurses will be and academia guided development of the project, including design of survey instruments and focus a crucial factor in addressing this need as part of inter- group processes. The team also recommended the 2 – 5 professional team-based care models. recruitment of participants and codeveloped recom- mendations for action. See Appendix A for a list of There are more than 430,000 registered nurses (RNs) advisors. in California, the state’s largest group of licensed A statewide primary care survey and series of focus 6 health care professionals. The size and skill of this groups conducted in fall 2018 invited broad partici- potential workforce—currently underutilized in ambu- pation. Responses were received from 112 primary latory care—represents an opportunity to strategically care site leaders in various types of health care address the growing demand for lower-cost, more organizations, 199 RNs working in primary care set- tings, and 58 academic leaders of RN pre-licensure effective primary care through new care delivery nursing programs. The survey was designed to: models that use RNs to their maximum effectiveness. Team-based care can help address rising costs and $$Obtain information about the current primary care RN workforce, including the utilization of increasing demand as well. RNs and their roles. $$Consider the academic preparation and However, realizing this potential will require addressing readiness of nursing students for RN roles in the academic-practice gap with significant changes in primary care. the way nursing schools prepare students for practice $$Explore strategies supporting the preparation as well as the way primary care settings enhance and of the future nursing workforce in these deploy RNs’ knowledge, skills, and experience. practice settings. Focus groups were conducted in four geographical To acquire information to serve as a basis for specific regions of California. Participants were leaders in recommendations, an 18-month project, Improving organizations providing primary care, RNs practicing Capacity for Team-Based Care: The Registered in primary care settings in various roles, and RN pre- Nursing Workforce in Primary Care, was launched in licensure nursing program leaders and faculty. The focus groups were designed to validate and build January 2018. (See sidebar, About This Project.) The on the survey findings, providing opportunities to project investigated current nursing roles in primary explore issues in detail. These discussions informed care, academic preparation of RNs for work in ambula- the development of recommendations and strate- tory settings, and gaps between current practices and gies detailed in this paper. See Summary of Findings what will be needed in the primary care workforce of (page 3). the near future. Increasing Primary Care Capacity Through Academic Preparation and Effective Utilization of Registered Nurses in Team-Based Delivery 1 Trends and Driving The RN Workforce Traditionally, RNs have not had an extensive role in Forces the primary care workforce.13 However, as care models The health care environment is changing dramatically evolve to include prevention, wellness, management due to rising costs, increasing demand for services, of chronic conditions, and population health, RNs are shifting consumer expectations, workforce shortages, well positioned to assume roles and provide patient- payment restructuring, and policy changes.7,8 Two of focused care in all these areas.14,15 (See sidebar.16,17) the most notable trends impacting primary care and Baccalaureate-level nurses particularly have a ground- RNs are discussed below. ing in leadership, research, and public health that enables them to address complex health and commu- nity-based needs.18,19 The Institute of Medicine (IOM)’s Value-Based Payment and Care landmark report Crossing the Quality Chasm: A New Health care is transitioning away from hospital-centric Health System for the 21st Century identified nursing models of care delivery to those that address social as the largest component of the health care workforce determinants of health and are community based, in a key position to improve client safety and influence prevention and wellness oriented, and focused on the health care system.20 Evidence supports the impor- optimizing client health independence. This shift tance of RN roles working within interprofessional elevates the importance of primary care in improving teams in achieving better outcomes.21 Many of the client and population health (whether defined by geo- Affordable Care Act regulatory measures and Centers graphical boundaries or specific characteristics) and for Medicare & Medicaid Services (CMS) quality met- reducing cost.9–11 rics link to functions and competencies that are carried out through nursing roles and responsibilities.22 Changing payment models that tie payment to out- comes are setting new expectations for efficiency and effectiveness. Combined with growing demand and provider shortages, this is driving organizations Definitions providing primary care to develop new skill sets and Nursing is the protection, promotion, and optimiza- reconfigure their resources.12 Many are expanding tion of health and abilities, prevention of illness and capacity by implementing team-based, client-centered injury, alleviation of suffering through the diagnosis care models in which providers work collaboratively and treatment of human response, and advocacy in the care of individuals, families, communities, and with other team members to allow for larger patient populations. panels and additional services. — AMERICAN NURSES ASSOCIATION Professional ambulatory care nursing is a com- plex, multifaceted specialty that encompasses independent and collaborative practice. The com- prehensive practice of ambulatory care nursing is one