Voice of the President | March 2020

. . . nurse leaders are uniquely positioned to solve many of these problems, which will save lives and money.

This vision has helped to drive creative use of new and expanding medical technologies and systems to improve the overall value of care delivery. Broader emphasis is being placed on care coordination, chronic health care management, primary care medical homes and the use of telehealth. Nurses are essential partners and leaders in these developments and how they affect the delivery of care.

A growing body of research demonstrates the effect of social determinants of health (SDH) on health outcomes. According to the 2018 AHA Population Health, Equity and Diversity in Health Care survey, 77% of the respondents reported that SDH screening is taking place, and hospitals are providing non-medical services needed to address those social determinants, including providing transportation and nutrition services. Many hospitals are working with other stake-holders in the community—in fact, 91% percent of the hospitals have entered into at least one type of community partnership to address social determinants. Much more can be done and nurse leaders are uniquely positioned to solve many of these problems, which will save lives and money.

Issue highlights

Jo Ann Webb profiles Rep. Lauren Underwood (D-Ill.), a nurse leader who became an advocate for the nursing profession and health care access in Washington, D.C. Underwood’s example highlights that part of our roles as nurse leaders is to advocate for the profession and our patients outside of the organizations where we provide care.

In her article on the student and faculty experience at a refugee health clinic in San Antonio, Clarice Golightly-Jenkins discusses a collaborative model to address SDH. The clinic, known as the San Antonio Refugee Health Clinic (SARHC), provides free multidisciplinary health care to approximately 5,000 uninsured refugees living in the area. In addition to supporting the social and health care needs of the refugee community, the site provides experiential learning for students at University of Texas Health San Antonio School of Nursing. The SARHC is a great example of how nurses are engaged with interdisciplinary colleagues, community agencies and local churches to address SDH and improve the health of a vulnerable population.

The rapid development of innovative technologies enables nursing to support our communities in new and exciting ways, delivering care however and wherever it is best for the patient. In their article about a 24-hour cancer care clinic at Froedtert Hospital, Jayme Cotter and Tina Curtis discuss how the increasing complexity of outpatient care requires nurse leaders to think differently about how care is delivered in the ambulatory environment. They point out that ambulatory nurse leaders are in unique positions to design and/or facilitate this work, as care continues to shift to the ambulatory setting. They remind us that leaders must leverage relevant data and research to support the need for change and innovative care design, as this team did so successfully.

Shara Mayberry of Grady Health System details the work of EMS-mobile integrated health practice managers. This innovative care delivery program benefits patients in the community while improving the appropriate access and utilization of the health system. The program partners EMS staff and nurse practitioners to deliver and coordinate care for complex patients. Their partnership with the 911 system has responded to more than 3,000 calls, of which 44% were successfully managed in patients’ homes, rather than necessitating transport to an emergency department. Grady is expanding this model to address other hospital and community health care needs.

These are wonderful examples of how nurses are impacting care in the community. Reading these articles led me to research some others not highlighted in this issue.

Interdisciplinary care teams at Columbus Community Hospital in rural Nebraska huddle twice per day to discuss the needs and progress of each patient, essentially planning their care after discharge while patients are still at the hospital. Teams include three RN case managers, hospitalists, social workers, pharmacists, nurses and clinical therapists. The teams conduct risk assessments to identify patients more likely to be readmitted, such as those with a history of frequent emergency department visits or comorbidities. They examine SDH. This is also an example of how teams can work outside of the hospital—by strengthening communication and care plans with providers in the community including staff at skilled nursing facilities, home health agencies, assisted living facilities, retail pharmacies and medical groups. The result is that they were able to reduce readmissions by 42% and save $819,797 in just 18 months.

Another example is from Sharp HealthCare in San Diego. It has an interdisciplinary palliative care team providing in-home care 24/7 to patients with advanced chronic illness. The team provides in-home consultations with a focus on pain and symptoms, education and spiritual support for the patients’ care givers and assistance with treatment choices and advanced care planning. The team essentially addresses a mix of medical and social needs. Unlike hospice, the Transitions Program is delivered concurrently with ongoing treatment—patients continue to see their primary care physicians and specialists. This is an added layer of support, with 24/7 telephone access to Transitions nurses who can respond to crises when they happen. As a result of this program, Sharp has cut hospital admissions in half for these patients. And, for those that need to be admitted, the LOS for those admissions has been decreased by 50% or more. It also has seen significant savings per participant per month.

Finally, you may be familiar with the Community Aging in Place – Advancing Better Living for Elders model, funded by Medicare and Medicaid in 13 cities. There, an interprofessional team—consisting of an occupational therapist, a nurse and a repair person—keep older adults functioning at higher levels in their own homes and apartments by providing support to enhance their capacity to live independently. The Johns Hopkins School of Nursing is one institution participating in this program.

I also would like to raise awareness about AHA’s Hospital Community Cooperative (HCC). The HCC’s goal is to make it easier for hospitals and community organizations to partner to create health equity. Go to AHA.org and see the 10 inaugural teams that received funding support to develop innovative partnerships. Perhaps there is an opportunity for your organization to be engaged in the future.

According to a 2019 Gallup survey, nurses again are reported as the most trusted profession in the country––for the 18th year in a row! This trust is important as it demonstrates the public’s view of nurses as honest and ethical—which we know is key to patients engaging with health care systems. As leaders, we are caring for our communities in new and exciting ways, across the continuum of care. I am excited to share these examples of nurses who are leading the way to better health in their communities. I commend all of our nurse leader colleagues who are innovating, developing and demonstrating new ways to serve. I look forward to what we will accomplish throughout the rest of 2020. The AONL Annual Conference in Nashville provides a great opportunity for you to exchange information about the innovative work in the community your institution has undertaken. Hope to see you there!

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