By Debra Wood, RN, contributor
September 27, 2012 - Health care delivery continues moving to the outpatient setting, as America tackles the cost juggernaut, technology enables more procedures to take place in ambulatory centers and consumers assume more responsibility for their own care, creating additional opportunities for nurses.
Christine Colella, MSN, CNS, CNP, reported an increased demand for advanced practice nurses to deliver primary care.
“In health care, the desire is for more people to receive their care in an outpatient setting,” said Christine Colella, MSN, CNS, CNP, associate professor of clinical nursing and director of the nurse practitioner programs at the University of Cincinnati, College of Nursing, in Ohio. “It’s efficient and financially better than using the emergency department for everyday health care.”
Michelle Mercurio, national director of career services for Chamberlain College of Nursing, based in Downers Grove, Ill., added, “Outpatient care is the trend of the future and there will be more opportunity in this field for nurses.”
A growth in outpatient facilities
Components of the Affordable Care Act promote more outpatient services, teamwork, coordination between care settings and empowering patients to stay healthier in the community.
“It’s about trying to provide the most efficient care we can in the most appropriate environment,” said Kerrie Cardon, RN, AIA, ACHA, healthcare consultant for Herman Miller Healthcare in Zeeland, Mich..
Kerrie Cardon, RN, AIA, ACHA, expects changes in primary care visits and more reliance on nurse practitioners.
Health systems and insurers are investing in the outpatient arena. HCA’s TriStar Health and CareSpot, formerly Solantic, have established a joint venture to bring as many as 15 urgent care centers to middle Tennessee. The Ensign Group, a Mission Viejo, California-based operator of rehabilitation and long-term care facilities, purchased Doctors Express, a national urgent care franchise this year.
Insurer Humana purchased Concentra, an urgent care and primary care provider about two years ago. And Wellpoint, another insurer, has invested in Physicians Immediate Care, which provides management services to 20 independently-owned medical clinics in Illinois, Nebraska and Oklahoma.
CVS Pharmacy’s MinuteClinics, staffed by nurse practitioners, continue to grow. The research and consulting firm Merchant Medicine in Shoreview, Minn., reported in September 2012 that MinuteClinic now operates in 569 locations, which accounts for more than one-third of the 1,376 retail clinics now open.
Merchant Medicine also reported in its ConvUrgentCare Report that retail clinics have started offering chronic disease management, and urgent care centers have begun acting as medical homes.
Accountable care organizations and patient-centered medical homes will offer nurses opportunities to provide care coordination and case management.
“Registered nurses are educated to care for the whole patient in whatever setting they are in,” Colella said. “The utilization of registered nurses across all type of settings enhances the care that is delivered to the patient.”
The University of Cincinnati is preparing bachelor’s degree students by adjusting clinical options, such as more community nursing so they can experience working with the public.
“Treating the whole patient means you need to manage the nuances, to not only provide the care but do the case management and collaborate,” Mercurio said.
Michelle Mercurio called continually learning the mantra in nursing today.
Mercurio added that typical nursing roles, such as triage and monitoring patients, will not change; rather, opportunities will expand. She anticipates more clinic and physician practices will be hiring registered nurses and RN nurse managers.
“Nurses will need to cultivate their leadership, care management and collaborative skills,” Mercurio said. “The nurse will need further education to meet the complex issues of treatment in the outpatient setting.”
In a new position statement about the role of RNs in ambulatory care, the American Academy of Ambulatory Care Nursing said the shift in care to the outpatient setting has increased the need for professional nursing services, and those nurses provide not only complex procedural care but also support with decision making, patient education and coordination of services.
Cardon also expects more innovation with shared visits, in which patients learn as a group about self-care for their condition rather than one-on-one with the provider, which can improve throughput.
“Education is going to be so important to empower patients to be responsible for their own health care,” Cardon said. “We’re going to have to be smart consumers and use services smartly.”
Primary care delivery
Colella reported an increased demand for advanced practice nurses to deliver primary care, manage chronic conditions and instruct patients in preventive measures. She finds nurses often gravitate to the nurse practitioner role because they want to help patients before those people become so acutely ill they require hospital-level care.
As more than 30 million people join the ranks of the insured, they will likely seek more services, at a time when the country faces a physician shortage. Nurse practitioners are expected to provide more of the routine-care services.
“There’s been some discussion about how we can leverage nurse practitioners to provide a certain level of care, and I think we will see more of that strategy,” Cardon said.
The Institute of Medicine (IOM)’s Future of Nursing: Leading Change, Advancing Health report recommended using advanced practice nurses to the fullest extent of their abilities, and the profession is working to make that happen.
“It works really well for patients,” Colella said. “That focus on more prevention and well-managed patients comes in a big circle back to what IOM says.”
The University of Cincinnati requires precepted experiences in primary and specialty outpatient settings. Nurse practitioner students learn how to pick up subtle changes and educate patients to monitor their own health.
Preparing for a new outpatient world
Learning doesn’t stop at graduation. As health care continues to evolve, care moves to different settings and new research advances knowledge about best practices, nurses must remain vigilant in adjusting their practices accordingly.
“Continually learning is the mantra in nursing today, whether for advanced degrees or certificates, but also just for those skills needed to operate in that new environment,” Mercurio said.
Graduate degrees will help prepare nurses for opportunities in management and advanced practice nurses in delivery of direct care.
“Learning happens every day--doesn’t matter who you are or how long you have done this,” Colella said. “Every patient can teach you something different. You have to seize those opportunities, and the more you learn, the better care you give.”
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