NURSES’ ROLES IN EXPANDING ACCESS TO QUALITY HEALTH CARE

The United States spends more than $3.5 trillion per year on health care, 25 percent more per capita than the next highest-spending country, and under-performs on nearly every metric (Emanuel et al., 2020). Life expectancy, infant mortality, and maternal mortality are all worse in the United States than in most developed countries. In the United States, moreover, disparities in health care access and health outcomes are seen across racial lines; however, being able to use social and financial capital to buy the best health care is not necessarily associated with the world’s best health outcomes. Even among White U.S. citizens and those of higher socioeconomic status (SES), U.S. health indicators still lag behind those in many other countries (Emanuel, 2020). The U.S. population will not fully thrive unless all individuals can live their healthiest lives, regardless of their income, their race or ethnicity, or where they live. As discussed in Chapter 2, however, race and ethnicity, income, gender, and geographic location all play substantial roles in a person’s ability to access high-quality, equitable, and affordable health care. A variety of professionals from within and outside of health care settings participate in efforts to ensure equitable access to care. But the role of nurses in these efforts is key, given their interactions with individuals and families in providing and coordinating person-centered care for preventive, acute, and chronic health needs within health settings, collaborating with social services to meet the social needs of individuals, and engaging in broader population and community health through roles in public health and community-based settings.

Both in the United States and globally, the rapid growth in the number of older people in the population will likely lead to increased demand for services and programs to meet their health and social care needs (Donelan et al., 2019; Spetz et al., 2015), including care for chronic conditions, which account for approximately 75 percent of all primary care visits (Zamosky, 2013). The aging population will also bring change in the kinds of care the patient population will need. Older people tend to require more expensive care, and to need increasing support in managing multiple conditions and retaining strength and resilience as they age (Pohl et al., 2018). These realities underscore the importance of designing, testing, and adopting chronic care models, in which teams are essential to managing chronic disease, and registered nurses (RNs) play a key role as chronic disease care managers (Bodenheimer and Mason, 2016). Studies of exemplary primary care practices (Bodenheimer et al., 2015; Smolowitz et al., 2015) define key domains of RN practice in primary care, including preventive care, chronic illness management, practice operations, care management, and transition care.

Since the passage of the Patient Protection and Affordable Care Act, substantial changes have occurred in the organization and delivery of primary care, emphasizing greater team involvement in care and expansion of the roles of each team member, including RNs (Flinter et al., 2017). Including RNs as team members can increase access to care, improve care quality and coordination for chronic conditions, and reduce burnout among primary care practitioners by expanding primary care capacity (Fraher et al., 2015; Ghorob and Bodenheimer, 2012; Lamb et al., 2015).

In primary care, RNs can 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 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. (Bodenheimer and Mason, 2016, pp. 11–12)

Findings from a 2013 study of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP) suggest that a large majority of LEAP primary care practices, regardless of practice type or corporate structure, use RNs as a key part of their care team model (Ladden et al., 2013). This contrasts with a study of 496 practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care initiative (Peikes et al., 2014) that found that only 36 percent of practices had RNs on staff, compared with 77 percent of LEAP sites (Flinter et al., 2017).

The health needs of individuals exist across a spectrum, ranging from healthy people, for whom health promotion and disease prevention efforts are most appropriate, to people who have limited functional capacity as a result of disabilities, severe or multiple chronic conditions, or unmet social needs or are nearing the end of life. Access to quality health care services is an important SDOH, and equitable access to care is needed for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity” (ODPHP, 2020). Likewise, “strengthening the core of primary care service delivery is key to achieving the Triple Aim of improved patient care experiences, better population health outcomes, and lower health care costs” (Bodenheimer and Mason, 2016, p. 23). The 2011 The Future of Nursing report echoes these themes:

while changes in the healthcare system will have profound effects on all providers, this will be undoubtedly true for nurses. Traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care. (IOM, 2011, p. 24)

Given the increased evidence supporting the focus on addressing social needs and SDOH to improve health outcomes, these competencies are even more important a decade later. While progress has been made, there is still work to be done, and leveraging and expanding the roles and responsibilities of nurses can help improve access to care (Campaign for Action, n.d.).

For people who have difficulty accessing health care because of distance, lack of providers, lack of insurance, or other reasons, nurses are a lifeline to care that meets them where they are. Nurses work in areas that are underserved by other health care providers and serve the uninsured and underinsured. They often engage with and provide care to people in their homes, they work in a variety of clinics, they use telehealth to connect with people, and they establish partnerships and create relationships in schools and communities. In addition to expanding the capacity of primary care, nurses serve in vital roles during natural disasters and public health emergencies, helping to meet the surge in the need for care (see Chapter 8). Yet, the potential for nurses to advance health equity through expanded access to care is limited by state and federal laws and regulations that restrict nurses’ ability to provide care to the full extent of their education and training (see Chapter 3). Ways in which nurses can fulfill this potential to increase access to care for populations with complex health and social needs are discussed below.

INCREASING ACCESS FOR POPULATIONS WITH COMPLEX HEALTH AND SOCIAL NEEDS

Many individuals cannot access health care because of lack of insurance, inability to pay, and lack of clinics or providers in their geographic area. To bridge this gap, access to care is expanded through a variety of settings where nurses work, including federally qualified health centers (FQHCs), retail clinics, home health and home visiting, telehealth, school nursing, and school-based health centers, as well as nurse-managed health centers. Across all of these settings, nurses are present and facilitate access to health services for individuals and families, often serving as a bridge to social services as well.

Home Health and Home Visiting

Visiting people in their homes can advance equitable access to quality health care. Home health care has increased access to care for many Americans, from older individuals to medically fragile children. Yao and colleagues (2021) recently explored trends in the U.S. workforce providing home-based medical care and found that less than 1 percent of physicians participating in traditional Medicare provide more than 50 home visits each year (a rate unchanged between 2012 and 2016). By contrast, the number of NPs providing home visits nearly doubled during that same period. Home health nurses address a fragmented system by coordinating care for patients transitioning from a tertiary care facility to ongoing health care within their own homes. Since the onset of the COVID-19 pandemic, these nurses have increasingly provided families with respite for caregivers and offered mental health services in many forms, but certainly in decreasing social isolation for elderly people. Delivering care at home has offered a window for physicians and NPs to see where patients live, to engage in telehealth video calls with family members present, and to see the features of neighborhoods that impact health (e.g., sidewalks, playgrounds, stairs).

With the expansion in the home health care industry driven by an aging population, home visiting nurses are essential to providing care and enhancing health care equity (Walker, 2019). Prior to 2020, Medicare rules allowed only physicians to order home health services for Medicare beneficiaries. However, the Coronavirus Aid, Relief, and Economic Security (CARES) Act permanently authorizes physician assistants and NPs to order home health care services for Medicare patients. In addition, CMS has instituted new policies outlining comprehensive temporary measures for increasing the capacity of the U.S. health care system to provide care to patients outside a traditional hospital setting amid the rising number of COVID-19-related hospitalizations nationwide. These measures include both the Hospital Without Walls and Acute Hospital Care At Home programs, both initiated during the pandemic. Under previous federal requirements, hospitals had to provide services within their own buildings, raising concerns about capacity for treating COVID-19 patients, especially those requiring ventilator and intensive care. Under CMS’s temporary new rules, hospitals can transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Provision for at-home care, which is often preferred by patients, is especially important during a crisis such as the pandemic, when hospital care means family and/or caregivers cannot be present. Moreover, some research has shown home care to be less costly and to result in fewer readmissions relative to hospital care (Levine et al., 2020). These programs also will create new demand for nurses to work in the community and are the types of adaptations that occurred as a result of the COVID-19 pandemic that should remain permanent to expand high-quality access to care.

The locus of care delivery will continue to follow personal preferences of individuals and families. To improve health care access, nurses will need to be intentional about meeting patients where they are in the most literal sense, and to serve as advocates with and within public health, retail clinics, and health systems to ensure that patients can access the care they need in their homes and neighborhoods. Box 4-1 describes several innovative nurse-led, in-home care programs.

BOX 4-1

Innovative In-Home Care Programs.

In addition to home health, nurse home visiting programs often include such services as health check-ups, screenings, referrals, and guidance in navigating other programs and services in the community (Child and Family Research Partnership, 2015). Growing evidence suggests that home visits by nurses during pregnancy and in the first years of a child’s life can improve the health and well-being of both child and family, including by promoting maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. This positive impact has been found to continue into adolescence and early adulthood (NASEM, 2019).

School Nursing

School nurses are front-line health care providers, serving as a bridge between the health care and education systems. Hired by school districts, health departments, or hospitals, school nurses attend to the physical and mental health of students in school. As public health sentinels, they engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children. School nurses are essential to expanding access to quality health care for students, especially in light of the increasing number of students with complex health and social needs. Access to school nurses helps increase health care equity for students. For many children living in or near poverty, the school nurse may be the only health care professional they regularly access.

School nurses treat and help students manage chronic health conditions and disabilities; address injuries and urgent care needs; provide preventive and screening services, health education, immunizations, and psychosocial support; conduct behavioral assessments; and collaborate with health care providers, school staff, and the community to facilitate the holistic care each child needs (Council on School Health, 2008; Holmes et al., 2016; HRSA, 2017; Lineberry and Ickes, 2015; Maughan, 2018). By helping students get and stay healthy, school health programs can contribute to closing the achievement gap (Basch, 2011; Maughan, 2018). According to Johnson (2017),

Healthy children learn better; educated children grow to raise healthier families advancing a stronger, more productive nation for generations to come. School nurses work to assure that children have access to educational opportunities regardless of their state of health. (p. 1)

Meeting the mental health needs of children can be particularly challenging. Researchers estimate that about a quarter of all school-age children and adolescents struggle with mental health issues, such as anxiety and depression. Approximately 30 percent of student health visits to the school nurse are for mental health concerns, often disguised by complaints of headaches and stomachaches (Foster et al., 2005). School nurses have experience with screening students at risk for a variety of such concerns and can assist students in addressing them (NASN, 2020a). However, most youth—nearly 80 percent—who need mental health services will not receive them (Kataoka et al., 2005); schools are not always equipped to deal with students’ emotional needs, and parents often lack the awareness or resources to get help for their children. Additionally, a recent study found disparities in access to mental health treatment for students along racial and ethnic lines (Lipson et al., 2018), and structural racism undergirds many risk factors for mental illness (see Chapter 2). The COVID-19 pandemic has revealed—and exacerbated—inequities among children of different incomes and races/ethnicities. School closures and social isolation have affected all students, but especially those living in poverty. In addition to the damage to student learning, the loss of access to mental health services that were offered by schools has resulted in the emergence of a mental health crisis (Leeb et al., 2020; Patrick et al., 2020; Singh et al., 2020).

Schools are increasingly being recognized not just as core educational institutions but also as community-based assets that can be a central component of building healthy and vibrant communities (NASEM, 2017). Accordingly, schools and, by extension, school nurses are being incorporated into strategies for improving health care access, serving as hubs of health promotion and providers of population-based care (Maughan, 2018). Yet, while there have been calls for every school to have access to a nurse (Council on School Health, 2016; NASN, 2020b), only 39.9 percent of schools employed a full-time nurse in 2017. The remainder of schools (39.3 percent) employed a part-time nurse or did not employ a nurse at all (25.2 percent) (Willgerodt, 2018). The availability and staffing levels of school nurses vary greatly by geography (Willgerodt, 2018) (see Figure 4-1).

Figure 4-1

Licensure staffing patterns (paid and unpaid volunteer) by geography. SOURCE: Data from Willgerodt, 2018.

To address the lack of health care resources in rural school settings, telehealth programs have been implemented with success (RHI, 2019). An example is Health-e-Schools, in which onsite school nurses connect sick students with health care providers. The program employs a full-time, off-site family NP who uses telehealth to evaluate and diagnose patients with such health issues as earaches, sore throats, colds, and rashes, as well as to provide sports physicals, medication, chronic disease management, and behavioral health care. It began as a telehealth program implemented by only 3 schools in 2011 and has since expanded to more than 80 schools serving more than 25,000 students. Health-e-Schools has helped increase classroom attendance and decrease the amount of time parents or guardians must take off from work to bring their children to appointments. This model relies heavily on the school nurses employed within each school district to serve as primary telehealth providers, thus requiring that funding be allocated to provide a school nurse in each school.

IMPROVING THE QUALITY OF HEALTH CARE

Access to comprehensive health care services is a precursor to equitable, quality health care. Nurses are uniquely qualified to help improve the quality of health care by helping people navigate the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is culturally respectful and appropriate. Nurses can help overcome barriers to quality care, including structural inequities and implicit bias, through care management, person-centered care, and cultural humility.

Care Management

In the current health care system, care is often disjointed, with processes varying between primary and specialty care and between traditional and emerging care sites. People may not understand the processes of the health care system, such as where they will receive care, how to make appointments, or the various providers with whom they may come into contact. Perhaps most important, patients may not understand why all the providers across settings where they receive care should be knowledgeable about the services they receive and the problems that have been identified to ensure seamless, continuous high-quality care. Social factors affecting people with complex health needs may also adversely affect their ability to receive optimal care. Care management, care coordination, and transitional care are activities that nurses perform as members of a health care team to decrease fragmentation, bolster communication, and improve care quality and safety. A care management approach is particularly important for people with complex health and social needs, who may require care from multiple providers, medical follow-up, medication management, and help in addressing their social needs.

Care management—a set of activities designed to “enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self-care”—helps ensure seamless care (CHCS, 2007; Goodell et al., 2009). The components of care management include care coordination, transitional care, and social care.

Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” It is needed both to overcome obstacles of the health care system, such as fragmentation, communication, and billing/cost, and to increase access (McDonald et al., 2007, p. 4).

Transitional care entails coordinating care for people moving between various locations or levels of care, providing navigation, coordination, medication reconciliation, and education services (Storfjell et al., 2017). The Transitional Care Model, developed by Mary Naylor (see Box 4-2), and the Care Transitions Intervention, developed by Eric Coleman, are prominent nurse-centered care models focused on the often disjointed transition from an inpatient hospital stay to follow-up ambulatory care. Both models engage people with chronic illness from hospitalization to postdischarge, and employ a nursing coach or team “to manage clinical, psychosocial, rehabilitative, nutritional and pharmacy needs; teach or coach people about medications, self-care and symptom recognition and management; and encourage physician appointments” (Storfjell et al., 2017, p. 27). Both reduce readmissions and costs (Storfjell et al., 2017).

BOX 4-2

Transitional Care Model.

Health care delivery models that incorporate social care have created critical roles for nurses in coordinating care across providers and settings and collaborating with other professionals and community resources to improve the health of individuals with complex health and social needs. Chapter 5 provides examples of nurse-centered programs incorporating social care. Nurses are vital to carrying out these functions of care management. Common to nurses’ roles are functions including providing care coordination, developing care plans based on a person’s needs and preferences, educating people and families within care settings and during discharge, and facilitating continuity of care for people across settings and providers (ANA, n.d.).

Cultural Humility

As discussed in Chapter 2, implicit bias can lead to discrimination against others. In particular, structural racism in health care compromises the ability to deliver culturally competent care (Evans et al., 2020).

Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession. (Villaruel and Broome, 2020, p. 375)

Nurses may contribute to structural inequities in how they facilitate or hamper access to quality health care services since they are frequently the first point of contact for many individuals who need care. Cultural humility—“defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions” (Agner, 2020, p. 1)—is therefore essential for nurses.

Cultural humility enables nurses to participate in more respectful partnerships with patients in order to advance health care equity. According to Foronda and colleagues (2016), cultural humility has been found to result in effective treatment, decision making, communication, and understanding; better quality of life; and improved care. In contrast, clinicians with implicit bias may show less compassion toward and spend less time and effort with certain patients, leading to adverse assessment and care (Narayan, 2019). Because implicit bias can negatively affect patient interactions and health outcomes, it is important for nurses to be aware of their bias and how it may directly or indirectly impact patient interactions and the quality of care they provide (Hall et al., 2015).

Multiple strategies exist to help nurses achieve cultural humility and manage implicit bias to ensure that they provide high-quality, equitable care. Chapter 7 details the importance of incorporating cultural humility in nursing education. Instead of focusing broadly on the general population, quality improvement interventions characterized by cultural humility focus on needs that are unique to people of color (POC) and tailor care to overcome cultural and linguistic barriers that cause disparities in care (Green et al., 2010). With this approach, data on disparities are used to assess an intervention, with an emphasis on addressing barriers that are specific to underrepresented groups (ANA, 2018; Green et al., 2010; Villarruel and Broome, 2020). Box 4-3 describes culturally and linguistically appropriate services, designed to equip nurses with the knowledge, skills, and awareness to provide high-quality care for all patients regardless of cultural or linguistic background.

BOX 4-3

Culturally and Linguistically Appropriate Services.

When nurses are educated and empowered to act at multiple levels—upstream, midstream, and downstream—they help reduce the effects of structural inequities generated by the health care system. This includes education about how structural inequities may affect their practice environments (as well as research and policy) and, by association, the people with whom they work in clinical and community-based settings (see the detailed discussion of nursing education in Chapter 7).

IMPLICATIONS OF COVID-19 FOR HEALTH CARE EQUITY

The COVID-19 pandemic has highlighted the pivotal role of nurses in addressing health care equity. During public health emergencies, nurses in hospitals and in public health and other community settings need to function collaboratively and seamlessly. The pandemic has heightened the need for team-based care, infection control, person-centered care, and other skills that capitalize on the strengths of nurses (LaFave, 2020). Broadening of scope-of-practice regulations and expansion of telehealth services during the COVID-19 pandemic have allowed nurses to practice to the full extent of their education and training, providing equitable care and increasing access to care.

The surge of critically ill people due to the pandemic created the need to rapidly increase the capacity of the health care workforce, especially to replenish workforce members who needed to quarantine or take time to care for sick family members or friends (Fraher et al., 2020). In response, multiple governors issued executive orders expanding the scope of practice for NPs. As of April 10, 2020, five states (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) had temporarily suspended all practice agreement requirements, providing NPs with full practice authority (AANP, 2020). Thirteen states (Alabama, Arkansas, Indiana, Massachusetts, Michigan, Mississippi, Missouri, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) had enacted a temporary waiver of selected practice agreement requirements. By December 7, 2020, executive orders had expired for Kansas, Michigan, and Tennessee, and all practice agreement requirements had been temporarily suspended for Kentucky, Louisiana, New Jersey, New York, Virginia, and Wisconsin (AANP, 2020). Maintaining these broadened scopes of practice for nurses after the pandemic has ended would increase NPs’ opportunities to increase access to quality health care for individuals with complex health and social needs.

Hospitals are also redeploying health care workers—physicians, NPs, nurses, and others—from areas with decreasing patient volumes (resulting from, for example, limitations on elective procedures) to higher-need intensive care unit (ICU), acute care, and emergency service areas. For example, nurse anesthetists have been redeployed from operating rooms to ICUs to intubate and place central lines for patients in the surge response to COVID-19 (Brickman et al., 2020). As of December 2020, CMS was finalizing changes that allow NPs to “supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians” (CMS, 2020a). These changes will help make permanent some of the workforce flexibilities that were allowed during the pandemic.

Although much attention has been paid to the dire need for health care supplies and hospital beds to treat patients with severe cases of COVID-19, less attention has been directed at impacts of the pandemic on communities; their ability to weather the crisis; and individuals’ physical, mental, and social health. Nurses, including public health nurses, working in and with communities continue to be critical to efforts to contain the COVID-19 pandemic, as well as other pandemics that may occur in the future.

CONCLUSIONS

Whether in an elementary school, a hospital, or a community health clinic, nurses work to address the root causes of poor health. As the largest and consistently most trusted members of the health care workforce, nurses practice in a wide range of settings. They have the ability to manage as well as collaborate within teams and connect clinical care, public health, and social services while building trust with communities. However, nurses are limited in realizing this potential by state and federal laws that prohibit them from working to the full extent of their education and training. The COVID-19 pandemic in particular has revealed that the United States needs to do a much better job of linking health and health care to social and economic needs, and nurses are well positioned to build that bridge.

Conclusion 4-1: Nurses have substantial and often untapped expertise to help individuals and communities access high-quality health care, particularly in providing care for people in underserved rural and urban areas. Improved telehealth technology and payment systems have the potential to increase access, allowing patients to obtain their care in their homes and neighborhoods. However, the ability of nurses to practice fully in these and other settings is limited by state and federal laws that prohibit them from working to the full extent of their education and training.

Conclusion 4-2: Nurses are uniquely qualified to improve the quality of health care by helping people navigate the health care system; providing close monitoring, coordination, and follow-up across the care continuum; focusing care on the whole person; and providing care that is culturally respectful and appropriate. Through a team-based approach, nurses can partner with professionals and community members to lead and manage teams and connect clinical care, public health, and social services while building trust with communities and individuals.

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