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The Newly Transformed Health Care System: How Nursing Can Prepare for Change

While we know that healthcare today is fragmented and inefficient, we also know that efforts are underway to shake up old systems and embrace innovation with promise. The elderly population continues to expand and so too does the demand for long-term care services, particularly for functionally impaired and chronically ill older adults. Services that support older adults require payment systems that change the status quo in a way that improves quality but does not break the bank. Health care payers are moving more toward a system of payment that relies on new philosophies of paying for value rather than rewarding volume in the old fee-for-service models. With the emergence of Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs), Medicare payments will shift and health care providers such as hospitals, clinics, physician practices, will need to redesign care delivery and redeploy the workforce in new roles and settings.

In these redesigned new markets, we will see new job titles and roles that will emerge. Care coordination and interprofessional collaboration will be key. In a recent research brief, Dr. Mary Naylor and colleagues dicuss how the nature of nurses’ jobs are set to change in this new redesigned system of care.

Nursing in a Transformed Health Care System: New Roles, New Rules (E. Fraher, J. Spetz & M. Naylor) Penn LDI Interdisciplinary Nursing Quality Research Initiative (INQRI) Report: Research Brief, June 015.

Mary Naylor is the Marian S. Ware Professor in Gerontology and Director of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Her extensive work bringing Transitional Care models to the attention of health systems and payers focuses on older adults with complex care needs, emphasizing care coordination, and changing how we look at Long Term Services and Supports (LTSS). We asked her to elaborate on her recent article by answering 3 Questions!

Veronica D. Feeg, PhD, RN, FAAN

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Mary Naylor Photo


Mary Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology and Director of the New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, INQRI Program Director

Question 1. In a recent brief, you and your colleagues described new roles for nurses in a redesigned health care system.  Can you describe these roles and their importance to advancing the health of our society.


To listen, click here.

This is an extraordinary time for nursing and for health care and I was delighted to have the opportunity to work with my colleagues Erin Fraher and Joanne Spetz working as part of the Robert Wood Johnson Foundation INQRI (Interdisciplinary Nursing Quality Research Initiative) along with the Leonard Davis Institute on a brief that attempts to bring to the fore some of the – on the one hand tremendous opportunities we have and some of the challenges that we have currently and responding to them.

So nursing, I think has an enormous chance right now to capitalize on changing needs – vastly changing needs of  populations. We focused in the brief on just one example, older adults who are waking up every day with multiple chronic conditions: some of whom are going to be in that state and experiencing the challenges of these health changes for a long time; some of whom are near end of life and need to have a different set of services to meet their needs. So one of the big factors contributing to changes in expanded roles for nursing are the vastly changing needs of our populations.

We are seeing also this enormous change in  delivery system models and much of this is driven by how important it is for our society to recognize that we have to adapt; we have to deliver a different set of health services; we have to engage a different set of health partners. So newer delivery models, I don’t know if they are new today, but patient centered medical homes, accountable care organizations and cross cutting these models are strategies or approaches to care delivery, such as population health insuring and improving care coordination. So these are different I mean, this is not the same old delivery system that we’ve been working in for years, but rather a vastly changing delivery system which has not yet reached where necessarily its going; but the path taking the changing needs of the population and the expansion of competencies of nurses who are exquisitely prepared to address these needs and could get even more prepared in the future to be able to take advantage of and lead a change – I think all of these seemed to align during this period time. So we wanted to highlight that in this brief.

Question 2. How has your team’s work on the Transitional Care Model influenced your thinking about future nursing roles?

To listen, click here.

Well I think the transitional care model is a terrific exemplar that is evidenced based. It’s proven about the contribution that nurses can make in this evolving health care system. So we’ve had the great fortune for many years to both better understand what it’s like to be a consumer of health services; what it’s like to be someone coping with/confronting major challenges in health largely chronic illness; what it’s like to have to try to navigate our health care system as patients and families are increasingly being asked to take on roles and responsibilities related both to their health and coordinating their care; and how it is that nurse led solutions such as the transitional care model can make that better – can both help people more immediately address their needs and at the same time can really help them as they try to interact with multiple clinicians in multiple settings.

So it is essentially saying to patients and families caregivers “you’re not out there alone! That part of what we do in our health care system is not only help you meet your needs, but also to make that journey as easy as possible” – especially given the stress that these patients and families are under.

So the Transitional Care model helped us to understand much more intimately the needs of a population whose health is changing all of the time and also helped us to understand how nurse led solutions, which are team based, which capitalize on the gift of physicians and social workers and every other member of the care team, but how all of that which has a nurse as a quarterback better positions the people that are counting on us to have their needs meet in a much more timely manner. And to do that in a way that makes much efficient use of resources.

Question 3. From your perspective, what needs to happen to ensure widespread use of nurses in these new roles.

To listen, click here.

Well I think nurses really, really need to understand that right now we’re going through major system redesign. It has enormous implications for the discipline and for specific roles that nursing will play. And so we need to be major partners in that system redesign because the workforce implications are emerging simultaneously. I think it is essential that we: commit ourselves as a profession and to develop some of the expanded competencies that are really at the forefront of system redesign – so this work around patient engagement and family care giver engagement the competencies needed to manage complexity help people manage both the health and social risks that they are experiencing in their communities; understand what it means to be able to take on this construct of population health which is  to say we know how to not just care well for individuals or groups of individuals but we know how to care for the population of individuals  in communities; understanding how to use and bring to the fore skills in managing  the care of populations over time.

I also think  it is essential  that competencies around teams which are (you know we hear about everyday how important teams are) but when we actually have a grounding a socialization a history of working in partnership with other health clinicians in partnerships with community based organizations whom I think are emerging as core members of future teams – those that are based in service organizations helping people to get their meals and their transportation, helping them get their copays for their medications. And finally I think competencies around performance improvement. There is nothing that is going to be static about our health care system and nurses really need to understand  how to risk stratify populations so they can best match needs with services available. They need to: understand processes that continually enable them to get better; how to use data big and small to improve the quality of what they do; and how to be great stewards of resources.

So I would say that the needs right now are for every part of our system – our leadership our educational systems and our practice environments to be aligned in working to make sure that nurses emerge, not just with a central role because that’s what we are hoping for our profession, but  emerge as the providers  – key  providers – of services because they are the best positioned to be able to accelerate improvements, redesign, and better care and outcomes for our society.

Additional Follow-up. Do you have anything else you might to add to advice for nurses?

This is a really good time not just to be at the table. It’s essential time, obviously, to be at the table, but to be able to represent all of the possibilities that are grounded in evidence about ways in which nurses contribute as members of teams as team leaders as coordinators. So when you have that chance to be at the table, make sure that you’re there as the most exquisitely informed and articulate spokesperson for the range of possibilities that will enable nursing’s voice to be heard, nursing’s contribution to part of future health system redesign.