Executive Summary
Increased access to health insurance and health care, increased complexity of patients in our aging society, and challenges in primary care team staffing are among many current challenges to providing high quality, effective, and satisfying care to all patients. At the same time, the team is expected to attend to the equally important need for prevention, health promotion, and care coordination and management of the population at large. The demand to manage multiple, comorbid complex chronic illnesses are overwhelming the primary care system and causing waits, delays, and a shifts toward receiving primary care in inappropriate settings such as the emergency room (ER).
Solutions cannot be limited to producing more physicians, nurse practitioners (NPs), and physician's assistants (PAs) as primary care providers, but rather in looking at all members of the primary care team and ensuring that each member is contributing at their highest level based on education, training, and licensure/certification. One professional, the registered nurse with a Bachelor of Science in Nursing (BSN-RN), has traditionally been underutilized as a core member of the primary care team. Supporting BSN-RN practice as a key member of the primary care interprofessional team is a strategy that will help meet the needs of our patients. BSN-RNs have the knowledge, skills, and abilities to assume critical roles in prevention, health promotion, management of acute and episodic illness, chronic illness management, transition management, and complex care management and coordination, as well as supporting the work of the entire interprofessional team (
Josiah Macy Jr. Foundation 2016
; American Academy of Ambulatory Care Nursing ([American Academy of Ambulatory Care Nursing 2012
).Transforming the role of the BSN-RN in primary care requires the coordinated responses of policy makers, academic institutions, accrediting bodies, primary health care providers and other primary care team members. In 2015, the Health Resources and Services Administration (HRSA) provided financial support (HRSA-16-066) to nine universities to develop educational models that provide BSN students to gain more clinical experience in community settings (
Health Resources and Services Administration 2015
). In late 2017, building on those successes, HRSA initiated a new funding initiative (HRSA-18-012) and called for proposals addressing strategies focused on recruiting both current and future nurses to practice careers in primary care, utilizing their full scope of practice as a member of primary care teams (Health Resources and Services Administration
Nursing education, practice, quality, and retention- Bachelor of Science in Nursing practicums in the community.
Nursing education, practice, quality, and retention- Bachelor of Science in Nursing practicums in the community.
http://bit.ly/HRSA_NEPQ16066
Date: 2015
Health Resources and Services Administration 2017
). Fundamental learning from these projects demonstrated that BSN-RNs are an essential component for quality care. Therefore, policies which impede primary care organizations from investing in the BSN-RN as a core member of the primary care team must be addressed.Health Resources and Services Administration
Nurse education, practice, quality and retention (NEPQR)- Registered Nurse in primary care (RNPC) training program.
Nurse education, practice, quality and retention (NEPQR)- Registered Nurse in primary care (RNPC) training program.
http://bit.ly/HRSA_RNPC_18012
Date: 2017
Background
The Centers for Disease Control and Prevention ([
Centers for Disease Control and Prevention 2017
) reports seven out of ten deaths are related to chronic disease and 86% of our health care costs are related to the management of chronic illness. More patients with untreated chronic illness are in primary care organizations after gaining access to health insurance through the Affordable Care Act (ACA). The number of individuals without health insurance has dropped from 16% to 9.0% from 2010 to September 2017, and there has been an increase in insurance coverage by both public and private insurance (Clarke et al., 2017
, Martinez et al., 2017
). 1
The proportion of citizens with access to usual medical care has increased steadily and simultaneously, with 88.7% reporting access to medical services in the first 6 months of 2017 (It is worth noting that this change has not been equilateral; rates of not being insured remain higher among people who are Black, Asian, Hispanic people, poor or near poor, and/or live in a state without Medicaid expansion (
Barnett and Berchick, 2017
, Martinez et al., 2017
)Clarke et al., 2017
). Many of these newly insured individuals have at least one long-standing chronic complex health condition that has not been addressed due to their lack of access to primary care services. Providers are also seeing an increased incidence of chronic health conditions among US adults that require closer observation and management including obesity (31.5%, age 20 and over) and diabetes (9.8%, age 18 and over) (Clarke et al., 2017
). Newly insured patients and existing primary care patients with chronic conditions will worsen over time if not adequately managed.In June 2016, the Josiah Macy Jr. Foundation convened a group of national experts to address the need to transform primary care and promptly identified the need to change the culture of healthcare and transform the practice environment. Their recommendations called for the development of primary care expertise among nursing school faculty and subsequent education of nursing students in the role of the nurse in primary care as well as provision of support for the career development and opportunities for interprofessional education nurses with a BSN. A report released following the conference highlighted the value of RNs in primary care and their ability to take an expanded role in chronic disease management, care coordination, and preventive care (
Berkowitz
; Josiah Macy Jr. Foundation 2016
, Wojnar and Whalen, 2017
). Approximately one fifth of the nearly three million RN work force in the United States (US) is employed in ambulatory care settings including primary care and other practice areas (e.g. home health); a 15% growth in employment of registered nurses in primary care is expected by 2026 (Bureau of Labor Statistics, U.S. Department of Labor 2018
).Registered nurses have frequent contact with patients in primary care and have more flexibility in their schedule to accommodate for individual and group-level interventions. Further, utilizing BSN-RNs has the potential to reduce the burden on advanced practice health care providers, and to increase revenue by increasing both the number of patients that can be seen in a day and creating additional time for primary care providers to see more complex patients (
Norful et al., 2017
; - Norful A.
- Martsolf G.
- de Jacq K.
- Poghosyan L.
Utilization of registered nurses in primary care teams: A systematic review.
International Journal of Nursing Studies. 2017; 74: 15-23https://doi.org/10.1016/j.ijnurstu.2017.05.013
Needleman, 2016
; - Needleman J.
Expanding the role of registered nurses in primary care: Business case analysis.
Bodenheimer & Mason (2017) Registered Nurses: Partners in transforming primary care. Proceedings of a conference on preparing registered nurses for enhanced roles in primary care. Josiah Macy Jr. Foundation,
New York2016: 112-139
Smolowitz et al., 2015
). The main responsibilities of BSN-RNs in the primary care setting are related to culturally competent episodic and preventive care and chronic disease management including: conducting telephone triage and health coaching, assessing and documenting health status, reconciling medications, providing case management for patients with chronic illnesses, and managing transitions to/from hospital care (Flinter et al., 2016
, - Flinter M.
- Blankson M.
- Ladden M.
Registered Nurses in primary care: Strategies that support Practice at the full scope of the Registered Nurse license.
in: Bodenheimer & Mason (2017) Registered Nurses: Partners in transforming primary care. Proceedings of a conference on preparing registered nurses for enhanced roles in primary care. Josiah Macy Jr. Foundation,
New York2016: 89-110
Smolowitz et al., 2015
). Standing orders enable BSN-RNs to take responsibility for determining which vaccines and immunizations to administer, beginning or adjusting medication regimens following provider-established protocols, and coordinating care of patients with chronic conditions (Norful et al., 2017
). In addition, BSN-RNs continue to provide their traditional services of patient education and health promotion, chronic illness and symptom self-management, and conducting relevant health screenings (e.g. health literacy) and risk assessments (e.g. tuberculosis exposure, substance use) (- Norful A.
- Martsolf G.
- de Jacq K.
- Poghosyan L.
Utilization of registered nurses in primary care teams: A systematic review.
International Journal of Nursing Studies. 2017; 74: 15-23https://doi.org/10.1016/j.ijnurstu.2017.05.013
California Healthcare Foundation 2015
, Cawthon et al., 2014
, - Cawthon C.
- Mion L.C.
- Willens D.E.
- Roumie C.L.
- Kripalani S.
Implementing routine health literacy assessment in hospital and primary care patients.
The Joint Commission Journal on Quality and Patient Safety. 2014; 40: 68-76https://doi.org/10.1016/S1553-7250(14)40008-4
Lunstead et al., 2017
; Josiah Macy Jr. Foundation 2016
; Norful et al., 2017
).- Norful A.
- Martsolf G.
- de Jacq K.
- Poghosyan L.
Utilization of registered nurses in primary care teams: A systematic review.
International Journal of Nursing Studies. 2017; 74: 15-23https://doi.org/10.1016/j.ijnurstu.2017.05.013
There is evidence that the skills of the BSN-RN can be utilized effectively in managing patients across the continuum of care. High performing teams who participated in the Robert Wood Johnson Primary Care Teams: Learning from Effective Ambulatory Practices (PCT-LEAP) program that led effective team-based care with BSN-RN care coordination noted that BSN-RNs played a pivotal role in preventive health and chronic care management and practiced autonomously in many of these domains. (
Flinter et al., 2017
, - Flinter M.
- Hsu C.
- Cromp D.
- Ladden M.D.
- Wagner E.H.
Registered nurses in primary care: Emerging new roles and contributions to team-based care in high-performing practices.
Journal of Ambulatory Care Management. 2017; 40: 287-296https://doi.org/10.1097/JAC.0000000000000193
Wagner et al., 2017
). BSN-RN responsibilities in high-performing primary care organizations have been found to increase access to healthcare services, decrease hospital re-admission, ER use, and overall costs of care, and improve quality of care, patient outcomes, and staff satisfaction (Lamb et al., 2015
, Parker et al., 2017
, Smolowitz et al., 2015
).Nurse-led interventions for management of chronic conditions have resulted in improved adherence to treatment plans (
del Rey-Moya et al., 2013
); self-confidence and accountability in the management of their illness and symptoms (Swercek et al., 2013
); and significant reduction in blood pressure and cholesterol levels (Brown, 2017
). Similarly, physical activity interventions led by nurses resulted in increased frequency, duration, and intensity of physical activity among patients as well as significant improvement in health status (Dubbert et al., 2002
, Dubbert et al., 2008
, Kinnunen et al., 2007
, - Kinnunen T.I.
- Pasanen M.
- Aittasalo M.
- Fogelholm M.
- Weiderpass E.
- Luoto R.
Reducing postpartum weight retention: A pilot trial in primary health care.
Nutrition Journal. 2007; 6 (Article 21)https://doi.org/10.1186/1475-2891-6-21
Murchie et al., 2003
, Piette et al., 2011
). BSN-RNs can also help increase access to care in other aspects of primary care as well, such as the primary prevention of infectious diseases, which includes the promotion, education and administration of established vaccine protocols (Hoekstra and Margolis, 2016
). In California, RNs in some primary care sites have the authority to dispense and/or administer hormonal birth control following a set protocol, which resulted in a 10% increase in access to contraceptives in sites that have implemented these policies (Parker et al., 2017
). Moving forward, the role of the BSN-RN in primary care could also include assisting with management of patients using telehealth services (Pittmann and Forrest, 2015
). Similarly, as primary care organizations increasingly include integration of behavioral health providers and step up to play major roles in addressing the opioid epidemic, the role of BSN-RNs on the team for support, education, patient monitoring, and safety is another opportunity for BSN-RNs to make a major contribution.The transition in payment system to payment for outcomes is ready for the role of the BSN-RN in primary care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) designed a quality program that repealed the sustainable growth formula, pays providers for quality versus volume, streamlines quality programs under Merit-based Incentive Payment System (MIPS), and gives bonus payments for participating in the alternative payment models (CMS.gov).
Thomas et al., 2016
noted the innovative role of the BSN-RN in primary care is intended for this transition in payment. The BSN-RN in primary care is prepared to provide intensive chronic care management, hospital care coordination, primary care coordination and transitional care, use of data, evidence, other performance improvements skills, Quality Improvement, and leadership. These same skills are needed to assist primary care organizations to achieve Patient-Centered-Medical-Home (PCMH) recognition. Lack of information of the BSN-RN role and interprofessional team-based care in primary care by public health campaigns, the media, and policy makers create barriers to the expansion of the role of the BSN-RN.- Thomas T.W.
- Seifert P.C.
- Joyner J.C.
Registered nurses leading innovative changes.
OJIN: The Online Journal of Issues in Nursing. September 30, 2016; 21 (Manuscript 3)https://doi.org/10.3912/OJIN.Vol21No03Man03
The scope of practice for RNs varies from state-to-state and could benefit from being standardized to RNs across the country. One step toward standardization of scope of practice is the January 2018 National Council of State Boards of Nursing (NCSBN) implementation of uniform licensing requirements as part of an enhanced nursing licensure compact (eNLC). In the absence of uniform licensing as a part of the enhanced nursing licensure compact, patient care may be hindered by RNs’ inability to provide and coordinate care across state lines. In contrast, nurses who are licensed in one of 36 participating states and who meet uniform licensing requirements (see
National Council of State Boards of Nursing 2018b
) may obtain a multi-state license allowing them to practice in other states, including via telehealth.National Council of State Boards of Nursing
Uniform licensure requirements for a multistate license.
Uniform licensure requirements for a multistate license.
https://www.ncsbn.org/ULRs_1_19_18.pdf
Date: 2018
Similarly, the APRN Consensus Model was developed in
APRN Consensus Workgroup and the National Council of State Boards of Nursing APRN Advisory Council 2008
and the National Council of State Boards of Nursing 2018a
. This document outlines the licensure, accreditation, certification, and education recommendations for APRN. Many national nursing RN and APRN organizations have endorsed the model. However, without state Boards of Nursing (BON) accepting the model as a uniform standard for licensure across state lines, the ability for the APRN to provide services via COMPACT or eNLC prohibits this from happening. This is another barrier for population health management for border state practices.A drastic shift is needed across these areas if we are to move away from our current primary care system and transform the role of the BSN-RN to allow for the provision of efficient, effective, and sustainable health promotion, disease prevention, and chronic care management. In doing so, there is great potential to improve the healthcare access and health of our most vulnerable populations.
Response and Policy Options
The imperative to support the development of education and training opportunities for the BSN-RN workforce, followed by practice opportunities for BSN-RNs in primary care, is precipitated by the increasing age and complexity of diverse patients’ health conditions that require team based care inclusive of BSN-RNs. The recommendations from the Josiah Macy Jr. Foundation conference are specific, actionable, and timely. The recommendations call for leaders of primary care organizations and health systems to: (1) actively facilitate culture change that elevates primary care in BSN-RN education and practice, (2) develop primary care residencies for BSN graduate nurses to learn hands-on primary care practice, (3) redesign primary care practice care models to utilize the skills and expertise of BSN-RNs in meeting the healthcare needs of patients (with support from payers and regulators), (4) facilitate life-long education and professional development opportunities in primary care and support practicing BSN-RNs to pursue careers in primary care. In addition, healthcare organizations should partner with academic institutions to facilitate the implementation of interprofessional education and support nursing faculty to teach prelicensure and RN-to-BSN students the knowledge, skills, and perspective to be active members of primary care teams and (5) support the NCSBN full implementation of the APRN consensus model.
The Academy's Position
The American Academy of Nursing (The Academy) recognizes the need to transform the current primary healthcare model and supports the Josiah Macy Jr. Foundation's Conference Recommendations (
Josiah Macy Jr. Foundation 2016
). In a report to the U.S. Congress titled Roles of Nurses in Primary Care, National Advisory Council on Nurse Education and Practice 2012
recommended the Secretary of the Department of Health and Human Services and Congress provide educational support funding to promote interprofessional primary care education and nursing in the primary care workforce. We support this recommendation. The implementation of these recommendations will meet the long-term health needs of the population across the lifespan and the continuum of care. This is best met by the integration of BSN-RNs into the primary care team and supporting BSN-RNs to practice at the full scope of their professional licensure. The Academy seeks to inform its constituents, organizational partners, and the public of nursing's commitment to comprehensive, evidence- based, best practices supporting the necessity for BSN-RNs in primary care.Recommendations
The Academy supports a coordinated response by interdisciplinary health professionals, national and state level licensing bodies, and health care payers to support the BSN-RNs in primary care to practice to the full scope of their education and training, which will improve the health (and healthcare) of the nation. We offer the following recommendations:
- •The Academy supports a coordinated response by health professionals, including APRNs, physicians, PAs, pharmacists, and social workers to include BSN–RNs in primary care.
- •The American Nurses Association (ANA) and the State Nurses Associations (SNA) educate state legislators, policy makers, and BONs on the importance of removing barriers to enhance RN licensure to improve patient access to care.
- •SNA is urged to support BONs for RN's to practice at the full scope of their license.
- •Encourage CMS, insurers (state and private), and other payers of health care to consider the added value that BSN-RN care coordination provides to the interdisciplinary team model to facilitate change, especially among health profession shortage areas and facilities that serve medically underserved populations, when determining funding levels.
- •American Nurses Association, American Association of Nurse Practitioners, American Academy of Ambulatory Nurses, American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-Internal Medicine, American College of Surgeons, American College of Obstetricians and Gynecologists, and Association of Women's Health, Obstetric and Neonatal Nurses collaborate to transform the culture of the primary care setting by limiting BSN-RN time on non-nursing tasks and providing support, training, and networking for BSN-RN care coordination and patient management.
- •The Academy, ANA, and nursing profession work to increase the general public's understanding on the preparation, knowledge, skills, and role of the BSN-RN in primary care through professional articles, print and electronic media, social media, and public service announcements.
- •Provide an Academy liaison to the NCSBN to address barriers in state practice acts for BSN-RNs to practice to the full extent of their education and training guided by evidence-based protocols developed for preventive and chronic care and encourage state BONs to include BSN-prepared nurses.
- •The Academy and its partners collaborate with NCSBN to identify the barriers to full implementation of the APRN Consensus Model nationally.
- •Encourage nurses to use the Academy's Institute for Nursing Leadership to secure appointments on boards of primary care organizations and national insurance corporations such as the National Association Community Health Centers, the National Rural Health Association, Blue Cross/Blue Shield, United Health Care, etc. to educate and influence others on the necessity of embracing a culture change on the role of the RN.
- •Nursing organizations align to adopt a uniform policy/position statement which recognizes the importance of the essential role of the BSN-RN in primary care.
- •The Academy, through its Primary Care Expert Panel, educates state and national primary care associations on the essential role of BSN-RNs to interprofessional primary care team-based practice.
- •The Academy, ANA, and other professional nursing organizations strongly support funding for research to demonstrate the impact on broad based population health outcomes associated with the role expansion of the BSN-RN in primary care.
Acknowledgments
The authors of this policy brief express their appreciation to the members of the Primary Care and Care Coordination Expert Panel and Kim Czubaruk, Esq., American Academy of Nursing staff liaison to the Primary Care and Care Coordination Expert Panel.
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