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Nurses have been developing an infrastructure to support reform.


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Reforming health care is not a matter of paying for all Americans to access our chaotic, expensive health care system. According to the government report The Costs of Inaction: The Urgent Need for Health Reform, in 2007, 40% of obese adults weren't advised about exercise, and nearly half of children weren't routinely taught about healthful eating. Something has happened to our commitment to prevention. Consider the person with diabetes who can't get coverage for self-management and weight-loss coaching but is covered for a leg amputation caused by uncontrolled hyperglycemia.


Clinicians shouldn't have to be convinced of the need for health care reform. On April 14 the Center for American Progress released a report on how reform will affect physicians, nurses, and other providers. The center also sponsored a reaction panel that included the American Medical Association, the American College of Physicians, the American Academy of Physician Assistants, and the American Academy of Nursing, which I represented. I used the opportunity to focus on how nurses can help to build the infrastructure we'll need if we're to shift from an emphasis on acute care to one on health promotion, chronic care management, and primary care. Take the following examples.


Childbirthing centers. There are already more than 120 childbirthing centers nationwide operating with nurse midwives (in collaboration with physicians and hospitals) that have excellent clinical and financial outcomes. According to testimony presented in April by Ruth Watson Lubic, nurse midwife and founder of the Washington, DC, Family Health and Birth Center, to the DC Council Committee on Health, this model of care could save Medicaid alone almost $13 billion a year if it were the nation's frontline maternity service. We need funding to extend this childbirthing network, and we must reverse the Centers for Medicare and Medicaid Services' denial of payment of a "facility fee"-which hospitals continue to receive-to these centers.

Figure. Diana J. Mas... - Click to enlarge in new window J. Mason

Nurse-managed health care centers are another way to meet the need for community primary care services. The formation of these centers was supported in large part by grants to schools of nursing from the Health Resources and Services Administration to serve disadvantaged populations. Yet many cannot become a federally qualified health center (FQHC) because they're governed by university boards and therefore don't meet the requirement that 51% of FQHC governing boards consist of consumers. In addition, inadequate payment for NPs' services and managed care organizations' refusal to accept NP credentials as valid continue to be concerns.


Transitional care models. A study by Jencks and colleagues in the April 1 New England Journal of Medicine reported a 20% hospital readmission rate within 30 days of discharge among patients on Medicare. This is costly for Medicare and for the patient and family. Nurse researcher Mary Naylor has developed a model of care that uses advanced practice nurses to coordinate patients' transition from hospital to home. Such a model reduces 30-day mortality rates and saves Medicare more than $5,000 per patient. AARP has called on the government to include a transitional care benefit under Medicare.


We also have data on practices such as Transforming Care at the Bedside that can make acute care safer and more efficient. (For more information on nurse-led innovations, go to Nurses won't like everything that may be included in health care reform legislation, but we must be careful not to undermine progress. We should work to ensure that any reform effort removes the barriers to nurses' contributing to cost-effective health promotion. I urge you to speak to policymakers, friends, neighbors, and colleagues and lend your support to this opportunity to fix a system we know is broken.