An overview and policy implications of national nurse identifier systems: A call for unity and integration.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

Part 6. Education for value-informed nursing practice.

With the ongoing transition to value-based health care, a strong command of foundational economic concepts, like cost and value, and the ability to thoughtfully engage in value-informed nursing practice have become essential for the future of the nursing profession. Earlier in this six-part series, we explained value-informed nursing practice, its historical, economic, and ethical foundation, its promise for an environmentally responsible, innovation-driven future health care, and why its adoption requires a reframing of some of the nursing's professional norms and behaviors. This paper concludes the series with one of the most important issues-education for value-informed nursing practice. We begin by setting forth our vision of how nursing students will learn and apply value informed nursing practice, consider challenges that nurse educators will face, and offer some suggestions for engraining value into the consciousness of the nursing profession.

Value-informed nursing practice: What is it and how to make it a reality.

Nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day. Consequently, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. This article is Part 1 of a 6-part series on value-informed nursing practice. It describes the concept of 'value-informed nursing practice'-practice that focuses not only on outcomes, but also on the cost of care-as a new way to envision nursing practice.

The impact of the COVID-19 pandemic on the future of telehealth in primary care.

This policy paper reviews the history, use and significance of telehealth in primary care. The emergence of telehealth as a primary strategy to continue to deliver value based, timely primary care during COVID-19 is discussed with recommendations for future applications, payment and preparation of providers to continue to provide quality care of clients in the future using telehealth.

Value-Based Payment: What Does It Mean for Nurses?

Among the many lessons that have been reinforced by the SARS-COVID-19 pandemic is the failure of our current fee-for-service health care system to either adequately respond to patient needs or offer financial sustainability. This has enhanced bipartisan interest in moving forward with value-based payment reforms. Nurses have a rich history of innovative care models that speak to their potential centrality in delivery system reforms. However, deficits in terms of educational preparation, and in some cases resistance, to considering cost alongside quality, has hindered the profession's contribution to the conversation about value-based payments and their implications for system change. Addressing this deficit will allow nurses to more fully engage in redesigning health care to better serve the physical, emotional, and economic well-being of this nation. It also has the potential to unleash nurses from the tethers of a fee-for-service system where they have been relegated to a labor cost and firmly locate nurses in a value-generating role. Nurse administrators and educators bear the responsibility for preparing nurses for this next chapter of nursing.

Prevalence of Telehealth in Nursing: Implications for Regulation and Education in the Era of Value-Based Care.

Value-based care theoretically catalyzes the business case for telehealth. Hence, the purpose of this study was to define the proportion of a statewide nursing workforce who self-reported telehealth or telephonic nursing as their primary work setting in a U.S. state undergoing rapid transitions to value-based care. We conducted a secondary analysis of a 2017 statewide nurse relicensure survey (n = 10,851), overall response rate 99%. The focus of the analysis was registered nurses who reported that they were currently working in Vermont or serving residents of the state (n = 8,457). Analysis was limited to descriptive statistics. We found that 18.4% of respondents (n = 1,556) reported their employment status as "telehealth/ working as a telephonic nurse." Responding to a different question, 17.2% (n = 1,458) defined "telehealth/telephonic" as their primary work setting. Thus, nearly one fifth of nurses practicing in the state were employed in telehealth, a role for which there is scant preparation in nursing education. The multistate practice of roughly one third of these nurses highlights the importance of the Enhanced Nurse Licensure Compact and raises questions about global telenurse practice. Taken as a whole, these findings have profound implications for health care policy development and implementation, ongoing workforce development and analyses, nursing regulation, education, and continuing education. New and renewed skills are needed to provide safe, effective, culturally relevant telehealth, and virtual care.

Free Clinics and the Need for Nursing Action in Uncertain Political Times.

Free clinics have been a source of health care for uninsured and low-income Americans for half a century and serve some of the nation's most vulnerable within their home community. Despite parallels to nursing's significant involvement in the formation of free public clinics and commitment to care for all, there is paucity of nursing literature about free clinics. This article details the history of U.S. free clinics and the intersections among free clinics and value-based care, health reform, and tax reform, including the Patient Protection and Affordable Care Act of 2010 and the Tax Cuts and Jobs Act of 2017. Challenges impacting free clinics are detailed, as well as strategies nurses may employ to support survival of free clinics and enhance service to their target populations. Roles for nurses in free clinic governance, management, and practice are described as well as suggestions for research, education, and public policy.

From Single-Payer to All-Payer: Why Vermont's Reform Efforts Matter to U.S. Nurses and Their Patients.

In October 2016, the State of Vermont signed an unprecedented agreement (The All-Payer Accountable Care Model) with the Federal Government to completely reform how health care is delivered and paid for in Vermont. This innovative agreement builds on sweeping 2011 legislation that set Vermont on a course towards payment reform designed to eliminate the fragmentation, overtreatment, and high costs associated with fee-for-service reimbursement. The strong emphasis on care coordination, preventative care, the patient experience, and population health ensures a crucial and growing role for nurses in this innovative environment and provides a model to inform the nation. Such state-led reform may have particular importance during the Trump administration, given the expected emphasis on state's rights and state leadership.

What's at Stake in U.S. Health Reform: A Guide to the Affordable Care Act and Value-Based Care.

The U.S. presidential election of 2016 accentuated the divided perspectives on the Patient Protection and Affordable Care Act of 2010, commonly known as Obamacare. The perspectives included a pledge from then candidate Donald J. Trump to "repeal and replace on day one"; Republican congressional leaders' more temperate suggestions in the first weeks of the Trump administration to "repair" the Affordable Care Act (ACA); and President Trump's February 5, 2017 statement-16 days after inauguration-that a Republican replacement for the ACA may not be ready until late 2017 or 2018. The swirling rhetoric, media attention, and the dizzying rate of U.S. health and payment reforms both within and outside of the ACA makes it difficult for nurses, both United States and globally, to discern which health policy issues are grounded in the ACA and which aspects reflect payer-driven "volume to value" reimbursement changes. Moreover, popular and controversial elements of the ACA-for example, the clause that prohibits insurance carriers to deny coverage to those with preexisting health conditions and the more controversial individual mandate that bears Supreme Court support as a constitutional provision-are paired in ways that might be unclear to those unfamiliar with nuances of insurance rate determination. To support nurses' capacity to maximize their impact on health policy, this overview distills the 906-page ACA into major themes and describes payment reform legislation and initiatives that are external to the ACA. Understanding the political and societal forces that affect health care policy and delivery is necessary for nurses to effectively lead and advocate for the best interests of their patients.

Reducing Preventable Hospitalizations With Two Models of Transitional Care.

PURPOSE: Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of health care through temporary follow-up after hospital discharge. This study describes the approaches and outcomes of two distinct transitional care programs serving different populations: one is provided by master's-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPCs). Existing research has shown that transitional care programs with intensive follow-up reduce hospitalizations, emergency department (ED) visits, and costs. Few studies, however, have included side-by-side descriptions of the efficacy of transitional care programs varying by healthcare providers or program focus. DESIGN: This is a retrospective cohort study comparing the number of ED visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included differences in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program (September 2014 to December 2014) were analyzed (n = 98). The average age of participants was 69 years and 65% were female. Data were collected from patients from the PPC program from September 2014 to April 2015 (n = 71). Thirty participants died within 120 days after the intervention and were excluded; the remaining 41 were included in the analysis. Participants had an average age of 81 years and 63% were female. METHODS: For the CNS program, a secondary analysis of existing data was performed. For the PPC program, a review of patient charts was done to collect data on encounters. A Wilcoxon matched-pairs signed-rank test was performed to test for significance. FINDINGS: Patients in the CNS intervention had significantly fewer ED visits (p < .005) and hospitalizations (p < .005) in the 4 months after the intervention than in the 4 months before the intervention. Patients in the PPC program had a nonsignificant reduction in ED visits (p = .327) and a significant reduction in hospitalizations postintervention (p = .03). CONCLUSIONS: Both transitional programs have value in decreasing rehospitalizations. The CNS intervention also significantly reduced ED visits for their target population. Further study with randomized controlled trials is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed. CLINICAL RELEVANCE: Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.

Metric-driven harm: an exploration of unintended consequences of performance measurement.

Performance measurement is an increasingly common element of the US health care system. Typically a proxy for high quality outcomes, there has been little systematic investigation of the potential negative unintended consequences of performance metrics, including metric-driven harm. This case study details an incidence of post-surgical metric-driven harm and offers Smith's 1995 work and a patient centered, context sensitive metric model for potential adoption by nurse researchers and clinicians. Implications for further research are discussed.

Attitudes of nurses toward patient-directed dying: a pilot study.

Patient-directed dying (PDD) will be an increasingly common issue faced by healthcare professionals. Nevertheless, few studies have explored nurses' attitudes toward PDD. This pilot project sets out to fill the gap regarding nurses' attitudes and values regarding PDD and perceptions of consistency or inconsistency with the American Nurses Association (2001) Code of Ethics for Nurses With Interpretive Statements (The Code). Thirteen subjects self-selected from a population of registrants attending a national ethics conference by completing an anonymous descriptive survey. The majority of subjects noted that their personal and professional values related to PDD are in agreement (regardless of their specific position). The subjects were divided on whether PDD is ethically consistent with The Code. Despite being unsure if PDD is ethically consistent with The Code, these nurses found relief of suffering to be a more compelling rationale for PDD over patient autonomy. This study offers insight into key social and professional issues in which further research is needed and offers many avenues for further investigation.

Advanced practice registered nurse intended actions toward patient-directed dying.

UNLABELLED: Patient-directed dying (PDD) (also known as physician-assisted suicide) has been a heavily debated issue in the United States since the passing of the Death With Dignity Act in Oregon in 1997. Previous research surrounding PDD has been limited to assessing the attitudes of physicians, nurses, and patients. The purpose of this study was to describe the intended actions of advanced practice registered nurses (APRNs) toward initiating PDD discussions and prescribing a lethal dose of medication under PDD legislation. A survey design was used to guide this pilot study. An investigator-developed questionnaire was disseminated electronically to APRNs on a free professional Listserve in a rural northeastern state. The final sample was composed of 16 APRNs whose area of certification were identified as 63% family, 31% adult, 6% psychiatric/mental health, and 13% other. Hospice and palliative care employment experience was reported by 75% of the sample. RESULTS: The APRN subjects were more willing to engage in PDD discussions than to prescribe under PDD legislation. The APRNs reported an increased willingness to initiate discussions and prescribe when patient pain and suffering were explicitly stated. Seventy-five percent of APRNs viewed their personal and professional opinions regarding PDD to be synonymous even though 50% were unsure as to whether PDD was consistent with the American Nurses Association (2001) Code of Ethics for Nurses. CONCLUSIONS: Advanced practice registered nurses reported increased intent to discuss than actively participate through means of prescriptive authority under PDD legislation. The depiction of pain and suffering may have an impact on APRN intention to act in cases of PDD. RECOMMENDATIONS: Increased awareness and education surrounding professional codes for APRNs, particularly regarding PDD, are needed.