REGISTERED NURSES: PARTNERS IN TRANSFORMING PRIMARY CARE CARE IN TRANSFORMING PRIMARY REGISTERED NURSES: PARTNERS BODENHEIMER AND MASON Registered Nurses: Partners in Transforming Primary Care Proceedings of a conference on Preparing Registered Nurses for Enhanced Roles in Primary Care Chaired by Thomas Bodenheimer, MD, MPH and Diana Mason, PhD, RN, FAAN June 2016 Atlanta, Georgia ISBN# 978-0-914362-51-7 March 2017 This monograph is in the public domain and may be reproduced or copied without permission. Citation, however, is appreciated. Bodenheimer, T & Mason, D. Registered Nurses: Partners in Transforming Primary Care. Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June 2016; New York: Josiah Macy Jr. Foundation; 2017 All photos by Tony Benner. Accessible at: www.macyfoundation.org Registered Nurses: Partners in Transforming Primary Care Proceedings of a conference on Preparing Registered Nurses for Enhanced Roles in Primary Care Thomas Bodenheimer, MD, MPH and Diana Mason, PhD, RN, FAAN Atlanta, Georgia June 2016 Edited by Teri Larson Published by Josiah Macy Jr. Foundation 44 East 64th Street, New York, NY 10065 www.macyfoundation.org March 2017 CONTENTS Preface ......................................................................... 7 Introduction ..................................................................11 Conference Agenda ........................................................14 Conference Participants . 20 Conference Conclusions and Recommendations .....................23 Primary Care Exemplar West County Health Centers, Inc. in California .......................45 Primary Care Exemplar Community Health Center, Inc. in Connecticut .......................48 Primary Care Exemplar Clinica Family Health in Colorado. 52 Primary Care Exemplar Medical Associates Clinic in Iowa . 54 Commissioned Paper The Future of Primary Care: Enhancing the Registered Nurse Role . 57 Commissioned Paper Registered Nurses in Primary Care: Strategies that Support Practice at the Full Scope of the Registered Nurse License ........89 Commissioned Paper Expanding the Role of Registered Nurses in Primary Care: A Business Case Analysis .................................................113 Commissioned Paper Preparing Nursing Students for Enhanced Roles in Primary Care: The Current State of Pre-Licensure and RN-to-BSN Education. .141 Highlights from the Conference Discussion . .173 Selected Bibliography .................................................... 207 Biographies of Participants ..............................................211 4 5 6 PREFACE GEORGE E. THIBAULT, MD The 2016 Macy Conference, Preparing Registered Nurses for Enhanced Roles in Primary Care, represents the intersection of three important Macy Foundation themes. First, we have a long-standing interest in preparing health professionals for careers in primary care dating back to our 2010 Macy Conference, Who Will Provide Primary Care and How Will They be Trained?1 The preparation of an appropriately sized and skilled primary care workforce is critical to the success of a reformed healthcare system that better meets the public’s needs. Second, we have had a long-standing interest in improving nursing education to prepare nurses for leadership roles in a reformed healthcare system. This has been expressed by our support for interprofessional education2 and our promotion of the careers of nursing educators.3 This Macy Foundation theme also is very closely aligned with the recommendations of the Institute of Medicine’s Future of Nursing: Leading Change, Advancing Health4 report and the follow up National Academy of Medicine study of the impact of the report.5 Third, we have been very interested in working at the intersection of healthcare delivery reform and health professions education reform, believing that the close alignment of education and delivery reform is absolutely essential to achieve the common goal of both education and delivery—that is, better health of the public6. The idea for this conference was brought to us by the leadership of the American Academy of Nursing, and we will be partnering with the Academy in disseminating the recommendations to the nursing education community and the primary care practice community. The commissioned papers and the exemplar practice descriptions in this report make the case for change and show that these changes are achievable. But to make these enhanced roles for registered nurses more universal we will need to make progress in all six domains of the conference recommendations: 7 1. Changing the cultures in both nursing schools and practices to place greater value on primary care and the role of nurses in it. 2. Redesigning practices to make full use of the expertise of nurses. 3. Rebalancing nursing education to elevate primary care content. 4. Promoting the career development of nurses in primary care. 5. Developing primary care expertise in nursing school faculty. 6. Increasing opportunities for interprofessional education and teamwork development in both education and practice. The conferees felt strongly that there is great urgency in achieving all of these recommendations not only to meet patient needs, but also to enhance the professional satisfaction of nurses and all clinicians in primary care. This conference was a great success because of the experience, enthusiasm, and engagement of all the conferees. We had an outstanding planning committee that provided oversight for the commissioned papers, conference planning and execution, and the writing of the recommendations. And we had extraordinary leadership throughout the process from Diana Mason and Tom Bodenheimer. None of this would have happened without the meticulous administrative support provided by Yasmine Legendre. I am proud that the Macy Foundation has been able to make this contribution to nursing education reform and primary care transformation. George E. Thibault, MD President, Josiah Macy Jr. Foundation 8 1 Cronenwett L, Dzau V, conference chairs. Who Will Provide Primary Care and How Will They be Trained? New York, NY: Josiah Macy Jr. Foundation; 2010. 2 Josiah Macy Jr. Foundation. Conference on Interprofessional Education. New York, NY: Josiah Macy Jr. Foundation; 2012. 3 The Macy Faculty Scholars Program. http://macyfoundation.org/macy-scholars. 4 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 5 National Academies of Sciences, Engineering, and Medicine. Assessing Progress on the Institute of Medicine Report The Future of Nursing. Washington, DC: The National Academies Press; 2016. 6 Cox M, Naylor M, conference chairs. Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign. New York, NY: Josiah Macy Jr. Foundation; 2013. 9 10 INTRODUCTION THOMAS BODENHEIMER, MD, MPH DIANA MASON, PhD, RN, FAAN CONFERENCE CO-CHAIRS For primary care in the United States, it is the worst of times and the best of times. The gap is growing between the population’s need for primary care and the capacity of primary care to meet that need. Soon, the number of retiring primary care physicians will exceed the number of primary care physicians entering the workforce.1 The panel size of the average primary care physician is too large to allow for excellent acute, chronic, and preventive care. Physician burnout is widespread and increasing. Yet a renewed enthusiasm and spirit of innovation can be found in primary care practices across the country. And nurses—nurse practitioners and registered nurses (RNs)—are poised to rescue primary care. The number of nurse practitioners entering the workforce each year has mushroomed from 6,600 in 2003 to 20,000 in 2015. Nurse practitioners will increasingly be the primary care practitioners of the future. Of the approximately 222,000 nurse practitioners, 83.4% are certified in an area of primary care.2 Yet the ratio of primary care practitioners (including physicians, nurse practitioners, and physician assistants) to the population will still decline. Thus other professionals will be needed to care for the growing number of US adults with chronic conditions, as well as to focus on health promotion and address social determinants of health. Registered nurses, the largest health profession in the nation with over 3.5 million members, are ideally suited to provide the bulk of care for people with chronic illnesses. In primary care, RNs may assume at least four responsibilities: 1) Engaging patients with chronic conditions in behavior change and adjusting medications according to practitioner-written protocols; 2) Leading teams to improve the care and reduce the costs of high-need, high-cost patients; 3) Coordinating the care 11 of chronically ill patients between the primary care home and the surrounding healthcare neighborhood; and 4) Promoting population health, including working with communities to create healthier spaces for people to live, work, learn, and play. The number of RNs available to function in these enhanced primary care roles should be plentiful; from 2001 to 2014, the number of new nurses taking the NCLEX RN licensing exam more than doubled, from almost 69,000 to 158,000 per year.3 Already, 43% of US physicians are working with nurse care managers for patients with chronic conditions.4 And studies clearly show that RNs are qualified to perform these enhanced roles. For example, in a randomized controlled trial, diabetic patients with elevated blood pressures cared for by RN