1. Boston-Fleischhauer, Carol JD, MS, RN

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Disruptive changes in the way healthcare is organized and paid for must lead to changes in how care is delivered. The magnitude of transformation required by our policy makers, payers, and consumers will not be solely addressed through incremental care process or model improvement, which seeks to improve something that already exists. Instead, the delivery innovation itself must be disruptive to status quo.

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US healthcare is a highly complex enterprise with a cottage industry structure and includes many smaller-scale interdependent providers that act independently. This is in direct contrast to what policy makers and payers are demanding of providers and what consumers need, specifically, the provision of coordinated, integrated, and continuous care over the long haul.1 Organizations and systems are responding to this dichotomy by trying to put the disparate building blocks together; however, what does this mean for the nursing enterprise? Answering that question requires agreement on a few principles:


1. Disruption to how care is delivered in the United States requires a model that is cross-continuum in operations, not just in theory, but in fact organized to ensure that patients are consistently being cared for in the right "place" and "time" within the continuum that has been built.


2. Measured by total cost of care, a cross-continuum care model presumes dramatically decreased inpatient volumes and a tremendous expansion of services in the community, including but not limited to clinics, medical homes, cross-setting care management, remote monitoring, and home care. Acute care organizations embracing this disruption may or may not choose to own the continuum's components. Partnerships, affiliations, and agreements will abound.


3. Population health with be a key construct of model redesign, and patient partnerships will be fundamentally different than we have heretofore experienced.



To prepare for cross-continuum operations, the chief nursing officer (CNO) is fundamentally challenged to evaluate the current strategic plan for the entire nursing enterprise. More to the point, to ensure alignment of nursing resources with cross-continuum healthcare delivery, is cross-continuum role design for the professional nurse a priority in your strategic plan?


Disruption in Strategy

Instead of redesigning the role of the inpatient professional nurse first, and then working to clarify professional nursing roles elsewhere in your cross-continuum care system at a later point in time, start by confirming what the role of the professional nurse will be outside the walls of acute care, including ambulatory care, medical homes, post-acute care services, and home care. Then, evaluate how inpatient nursing can integrate within the broader cross-continuum nursing enterprise.


Remember, disruptive innovation challenges status quo thinking.2 As I travel throughout the country, I see that a flurry of professional role redesign work is occurring, but the overwhelming focus is the inpatient setting, with efforts to redesign how the acute care episode is supported. This work, though important, can serve to stifle the creativity and innovation needed for cross-continuum integration of nursing practice. The bottom line is that disruptive innovation in the redesigning of the role of the professional nurse means designing from the outside in versus the inside out.


For those multihospital or system nurse executives who already oversee cross-continuum services, this is admittedly a more logical proposition, albeit still overwhelming. Even so, CNOs in community hospitals are challenged to identify local network partners, be they freestanding post-acute care facilities to independent home health agencies, and work collaboratively to map what cross-continuum nursing needs to look like at the community level. In my conversations with nurse executives in post-acute care organizations, they report an eagerness to have these conversations, yet they are often looking to the acute-care CNO in the community to lead such efforts.


Furthermore, the need to vision and plan for implementing cross-continuum nursing practice is accelerating, because of systems' increased efforts to employ nurse practitioners (NPs) in key components of the care continuum. Absent clarification of what the role of the professional nurse could and should be in the healthcare cross continuum, we run the risk of underleveraging RNs and NPs alike, let alone creating tension, versus synergy, between these 2 roles in the broader care team structure.


Strategic Plan for Cross-Continuum Nursing

The strategic plan for achieving cross-continuum nursing practice must drive the following:


1. an integrated top of license practice model for nursing, with clarity as to prioritized functions and responsibilities in the community, in the inpatient setting, in medical homes, and in home care


2. decisions regarding manpower forecasting and planning to support your recruitment efforts


3. allocation of training resources to support the predicted transition of incumbents to roles outside the acute care microsystem


4. discussions with academic partners regarding how to design options for clinical rotations and experiences that mirror the vision of cross-continuum nursing practice


5. agreements regarding tools to support cross-continuum nursing practice, including but not limited to a cross-continuum plan of care and clinical analytics




Disruptions in the way healthcare is organized and paid for are leading to disruptions in care delivery. This shift requires us to plan for our future workforce differently. Designing your workforce from the outside in versus the inside out, and all that that entails, is perhaps one of the biggest disruptive shifts a CNO could make, yet is core to aligning the nursing enterprise with the direction of the organization. Allowing medical group leaders, physicians, human resources, or engineering consultants within our systems to address these solutions is wrong answer. CNOs must lead this planning effort to ensure preparation of a cross-continuum professional nursing enterprise that is prepared for the inevitable delivery system disruptions that lie ahead.




1. Grossman J. Disruptive innovation in healthcare; challenges to engineering. The Bridge. 2008; 38 (1): 10-16. [Context Link]


2. Christensen CM, Grossman J, Hwang J. The Innovator's Prescription. New York, NY: McGraw Hill; 2009. [Context Link]