Remarks to the 8th Annual Conference on Nursing Practice Based on Evidence

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by HRSA Administrator Mary K. Wakefield

April 1, 2011
Baltimore, Md.

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Thank you for the invitation to be here today.  Health policy has direct implications for health care and nursing practice, and to the extent that health policy influences nursing practice, research is an important foundation for both.  So the links between health policy, nursing practice and evidence are very important, as each impacts the other.

I always like to begin by telling my audience the range of activities HRSA is responsible for – and across these programs, by the way, research and evaluation are supported, data are collected, and metrics are established.

We use our $7.8 billion annual budget to manage 80 different grant programs in partnership with state, local and community organizations across the country:

• Our Community Health Center system supports more than 1,100 grantees that provide primary and preventive care at more than 8,100 clinical sites across the nation.  These grantees served about 19 million patients in 2009.
• Our National Health Service Corps places primary care professionals – including advanced practice nurses – in medically underserved areas in exchange for student loan repayments and scholarships.
• We strengthen the nation’s primary care workforce by giving financial support to colleges and universities – like this one – for training and curriculum development, and scholarship and loan repayments for students in the health professions.
• Our Maternal and Child Health block grants to states pay for health care services, screening and counseling that reach 6 of every 10 women in the U.S. who give birth and their infants.
• HRSA also administers the Ryan White HIV/AIDS Program, whose 900 grantees provide top-quality care and life-sustaining medication to more than half a million low-income and uninsured people living with HIV/AIDS.
• We house the Department’s Office of Rural Health Policy, which bolsters rural hospitals and coordinates coalitions of rural providers.  And we support the expanded use of telehealth to connect underserved people to distant providers through remote monitoring devices and teleconferencing.
• Finally, HRSA oversees the nation’s Poison Control Centers, federal organ procurement and allocation efforts, and the National Vaccine Injury Compensation Program, among others.

That’s a snapshot of what we do.  Now I want to tell you a bit about where we’re going.  Upon taking the administrator’s job in early 2009, I had my senior leadership rewrite HRSA’s strategic plan.  The new plan has four goals:

• To improve access to quality health care and services;
• To strengthen the health workforce;
• To build healthy communities; and
• To improve health equity and eliminate disparities in access to health care.

Clearly we need metrics in each area to determine progress toward these aims.  These goals align precisely with the goals of the Affordable Care Act.  When you read the provisions of that law, you see some themes emerge over and over: access, primary care, prevention, quality, care coordination.  And these are the themes that define HRSA’s work to reform health care in America.

Beyond these themes, HRSA and our partners are taking the steps required to put the Affordable Care Act into practice and dramatically increase health insurance coverage among the broader population.  HRSA is the lead agency responsible for implementing 50 provisions of the law and co-lead for implementing 16 others.

In many ways, the Affordable Care Act operationalizes what nursing students in their junior year in college know – that investing in keeping people healthy makes much more sense than focusing almost exclusively on care once they’re sick.  My ICU nursing experience reinforced that.  The folks who came through our doors with life-threatening conditions – which were often preventable – needed highly expensive care.  It’s an experience that, as a nurse, I saw over and over: the creation of a huge financial, physical and emotional toll on them and their families.

The Affordable Care Act recalibrates the focus of health care to strengthen primary care.  The biggest responsibility HRSA was given under the Act is about access to quality primary care.

The ACA invests $11 billion over the next 5 years for the operation, expansion, and construction of health centers throughout the nation. This support will enable health centers to nearly double the number of patients they serve by 2015.  19 million patients now; nearly double that in five years.  

Clearly, such a big expansion is going to require special attention to workforce.  Nurses are already playing a pivotal role in the expansion of HRSA’s health center system.  Health centers now employ 4,000 advanced-practice nurses, including clinical nurse midwives, and almost 11,000 RNs – and those numbers have grown by 20 percent over the last two years. 

With these investments in primary care through the ACA, you can expect continuing dramatic growth, adding substantially to what is already the single largest professional group in the health center workforce: their 15,000 nurses.

Sustaining the growth of the health center system and ensuring that other rural and urban underserved populations have access to primary care and clinical and preventive health services are immediate priorities for HRSA.

Fortunately, one of the more exciting provisions of the Affordable Care Act dedicates $1.5 billion to the National Health Service Corps over the next five years.  That’s enough to fund thousands of new loan-repayment contracts and scholarships for primary care clinicians.

These clinicians include nurse-practitioners, nurse-midwives, physicians and physicians assistants, dentists and hygienists, and mental and behavioral health professionals. In all, there currently are almost 1,400 advanced-practice nurses in the Corps, about 16 percent of all clinicians in the field.

And there are hundreds of vacancies at locations across the country.

If you’re not familiar with how the NHSC works, it boils down to this: HRSA pays down student loans or other academic debts in exchange for a commitment to practice in an underserved community for a set period.

To health care professionals who have never considered the NHSC, I urge you to go to www.nhsc.hrsa.gov and take a minute to look around. We’re also on Facebook at nationalhealthservicecorps – one word – to take any questions or comments you might have.

Those who join the Corps receive up to $60,000 in academic debt servicing for a two-year commitment -- and up to $170,000 for five years.  Loan repayments are tax-free.

For the first time in the 38-year history of the Corps, we’re also now accepting applications for part-time clinicians – those who might want to split time between a health center position and family commitments, or assume a teaching job while also working in a school clinic.

The Corps is all about increasing access to primary health care.

You should also be aware of the Affordable Care Act’s role in changing the way we think about health in America.  In specific ways, the ACA will foster a culture of wellness.

It looks to prevent future illness as much as it looks to solve the immediate problems people face today.  While relatively little-noticed by the public, prevention and health promotion are a major emphasis of the Affordable Care Act.

For example, through HRSA, the Act authorizes $200 million over the next four years for the construction, renovation and expansion of school-based health centers.  That way, even the most disadvantaged kids can get care conveniently – and get it before major health problems take root.  School nurses, of course, have been the backbone of school-based care – first responders to students – for years.

The Act also authorizes $1.5 billion over five years for a Maternal, Infant, and Early Childhood Home Visitation Program. Under this model, nurses, social workers and others will visit expectant mothers and their families in high-risk communities.  There, they will provide evidence-based counseling and intervention services known to have improved health outcomes for mothers, infants and families. 

States will use most of the funds to support the use of one or more of seven evidence-based home visiting models.  But the Act also encourages innovation by allowing for up to 25 percent of funds to support promising approaches that do not yet qualify as evidence-based models.

The common sense behind this evidence-based approach is obvious, as an article in the last issue of The American Nurse noted.  What good is it for health care systems to spend millions of dollars to provide care to babies in an ICU and then send them home with unprepared teenage mothers or other at-risk parents?  International research tells us that countries with nurse home visiting programs have lower infant mortality rates than the United States.

By the way, it was a nurse who was one of the innovators of this model, now firmly embedded because of the ACA.

In addition, the ACA funded community-based Nurse-Managed Health Centers that are managed by advanced practice nurses.  These clinics expand access to primary care for vulnerable populations and provide critical clinical training opportunities for nurses and other health professions students.

Going forward, the ACA supports the role of nursing professionals by authorizing millions of dollars to support nursing education and practice.

Let me mention two programs from the law that support the development and deployment of the advanced practice nursing workforce.  The Family Nurse Residency Program supports the transition of nurse practitioners into community-based practice by helping them develop skills to manage and support team-based care. The program also will help these nurses manage the complex care that primary care providers encounter when working with many high-risk and vulnerable patients.

And, again, through the Affordable Care Act, the Medicare Graduate Nursing Education Demonstration Program will increase the number of advanced practice nurses with skills in chronic care management and care coordination.

All this is just a partial list of how the Affordable Care Act benefits and supports nurses and the work we do.  To learn more about the ACA, I encourage you to visit www.healthcare.gov, a site that more than a million people have already visited.  

After just over a year analyzing the law and administering its components, it is clear to me that the Affordable Care Act assigns considerable responsibility to nurses. 

Care coordination in particular is a nursing-inspired and nursing-led issue.

We know, for example, that poor hand-offs between hospital and home are a principal cause of re-hospitalization among the chronically ill.

Nursing research led by Dr. Mary Naylor has shown that transitional care coordinated by advanced practice nurses has resulted in lower hospital readmission rates, higher quality outcomes for patients and their families, and lower costs.

On a broader level, care coordination is a core concept in quality efforts, and the regulations on accountable care organizations (ACOs) that were just posted yesterday are moving toward tying financial reimbursements to fewer hospital readmissions and fewer health care-caused infections.  Achieving gains in these areas will be predicated on care coordination and, obviously, nurses will play a key role.  Nurses are at the center of care coordination.

Care coordination is also included in President Obama’s budget for Fiscal Year 2012, which cites new, innovative models that rely on team-based care to deliver health care services.  He knows that these models – which include patient-centered medical homes and ACOs – hold the promise of a more effective and efficient health care system.

Interprofessional care, of course, implies cooperation and team-building across health care disciplines and roles.  HRSA is deeply involved in efforts to join with partners across the health care spectrum to push forward the concept of interprofessional care.

Our renewed focus on interprofessional, team-based care comes from a broadly recognized set of challenges in the way health care is currently delivered – challenges that currently result in compromised care quality.

As Secretary Kathleen Sebelius told the Senate Finance Committee just last month: “Too often, health care takes place in a series of fragments or episodes. We need to make it possible for entirely new levels of seamlessness, coordination, and cooperation to emerge among the people and the entities that provide health care, so as to smooth the journeys of patients and families … through their care, over time and in different places.”

The Secretary herself clearly knows what nurses know: that we have gaps in health care between sectors and among health care providers.  And these gaps put the health and well-being of patients at risk while driving inefficiency and associated increased costs that we simply cannot afford.

Our view at HRSA – with our responsibility for a number of health workforce programs – is that the Secretary articulated a problem which is partially amenable to how we educate and deploy our health care workforce.  Here’s how we’re engaging this agenda – and we’re not doing it alone.

In February, HRSA convened a meeting in partnership with Macy Foundation, the Robert Wood Johnson Foundation, the American Board of Internal Medicine Foundation, and the Interprofessional Education Collaborative (IEC) to examine competencies that would provide the foundation for interprofessional team-based care. 

The IEC is comprised of the following organizations, whose representatives were present at the meeting: the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health.

The representatives of these varied organizations worked with dozens of experts from government, academia and foundations to frame an action plan to advance the implementation of interprofessional competencies in health professions education and practice.

This gives you a sense of the breadth of interest in interprofessional care, and it’s a topic that other agencies in HHS are also engaging.  For that meeting, I was pleased to share the stage to kick off the event with CMS Administrator Don Berwick.  He also sees interprofessional care as a priority.

The gathering adjourned with a shared commitment among attendees to develop guidelines for the creation of interprofessional health care teams.  These guidelines will support patient-centered care in new delivery system models designed to improve care coordination, quality, safety and affordability – in other words, to address some of the very issues that Secretary Sebelius spoke about in her Senate testimony.

Going forward, the action plan to push interprofessional care includes four key strategies:

• Communication and dissemination of the interprofessional competencies and the business case for their value;
• Development of interprofessional faculty and resources – and training to develop interprofessional faculty that can teach to these competencies;
• Supporting research on metrics at the individual and team levels; and
• Development of new collaboratives with entities such as Kaiser and Geisinger to build interprofessional and practice partnerships.

This February meeting was launched in part from the work of the four HRSA health professions advisory committees that met jointly in 2010.  There they developed a framework of interdisciplinary team-based competencies for use in the classroom.

The work that I’ve described, and the work of the February meeting participants, informs a project we’re proposing to launch in 2012 that would offer primary care clinical training by both physician and nurse faculty using an interprofessional team approach to care.

The new project would provide competency-based training for about 1,000 primary health care providers, including nurse practitioners and residents.  Obviously, the budget process is evolving as we speak, but the inclusion of this initiative in the President’s budget is a clear signal about the administration’s commitment to interprofessional training and the importance of moving this agenda forward.

I understand that some of the more experienced among us may be thinking, “We’ve been down this interprofessional road before and nothing much came of it.”

I can’t argue with that, but I would argue, along with others, that it may be different this time.

For example, Dr. Stephen Shannon, president of the American Association of Colleges of Osteopathic Medicine, wrote recently that the past issues we wrangled with – access, costs and growing workforce shortages – now “have been joined by increasing recognition of team-based care’s potential to enhance quality – in health care, health promotion and disease prevention.”

“The growing evidence of how health teams enhance quality of care, coupled with the patient safety movement,” Dr. Shannon wrote, “has helped generate a significant amount of support for interprofessional education by leadership in the health professions and practice communities.”

“This is also joined by the hope that the medical home model of primary care will improve the practice environment and enhance the experience of health care delivery for both patients and practitioners,” he concluded.

Dr. Shannon went on to say that there’s still a lot we don’t know about how to implement this, and that research on the best way to provide interprofessional training still needs to be done – from how best to educate to how to engage teams in the context of difficult health care delivery models.

Clearly we’re entering a period of innovation in health care systems redesign, with the ACO announcement yesterday and much more to follow over the next couple of months.  If you’re open to change and a bit of risk-taking, all this adds up to what I think is a “moonshot moment” for health care and for nursing.

At HRSA we’re pushing forward on new fronts – for example the medical home model, which is something we want all of our health center grantees to adopt. And we are dedicated to helping all of them move toward becoming medical homes.

Because HRSA-supported community health centers employ a diverse group of health professionals, a good number of them have already begun to provide the team-based, interprofessional care that helps define medical homes.  Under this arrangement, everyone involved works to their fullest by redistributing care responsibilities to teams’ most appropriate, most capable, and most available clinicians – from pharmacists to doctors to nurse practitioners and others.

In addition, many health centers are deeply involved in other elements of the medical home model: HIT and information exchange, outreach, patient education, and integrating behavioral health and oral health into primary health care.

But while we’re on the threshold of this reorganization, there’s still much more to do.

That’s one reason we’ve partnered with the Centers for Medicare and Medicaid Services  on a three-year demonstration that will evaluate the impact of medical homes in improving care, promoting health, and reducing the cost of care provided to Medicare beneficiaries who are health center patients.

Five hundred health center sites are expected to participate in the demo, and HRSA is supporting the CMS’ Center for Innovation in developing technical assistance for it.

In another quality issue, we’re also working with CMS to add science-based measures on oral health, behavioral health, HIV/AIDS, rural health, prenatal health and immunizations to the measure set CMS uses to stimulate the adoption of HIT under its Meaningful Use Electronic Health Records Incentive Program.  

Because HRSA has a significant role in supporting the nation’s safety-net health care facilities, if we can add measures relevant to those providers, the financial incentives provided through the meaningful use initiative will encourage those providers to push ahead and adopt HIT.  And it looks like we’ll be successful in that.

Another reason for my optimism that we’re really at the cusp of opportunity is the release a couple of weeks ago of the National Quality Strategy by Secretary Sebelius.  The Strategy is designed to make the health care system work better by reducing health care providers’ administrative burdens and helping them collaborate to improve care.

The Affordable Care Act required HHS to develop the Strategy, and it continues the expectation contained in the ACA that evidence be the basis for moving forward in improving care quality.

Under President Obama, policy is pivoting off evidence.  This is an administration that believes strongly that the best policies are driven by data. 

So the new National Quality Strategy presents three aims for the U.S. health care system:

• First, Better Care, with a sharp focus on improving the overall quality by making health care more patient-centered, reliable, accessible and safe.  
• Second, giving attention to Healthy People and Communities by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.  So much of the nation’s health status has a lot more to do with what goes on outside of the health care system rather than what goes on inside it.   

• And third, Affordable Care: reduce the cost of quality health care for individuals, families, employers, and government – thus the focus on preventable hospital readmissions.

To achieve these aims through both public and private efforts, the Strategy establishes six priorities.  They are:

• First, making care safer by reducing harm caused in the delivery of care.   You’ll hear a lot more about this shortly – too many people seeking help are hurt in our health care systems today.
• Second, ensuring that each person and each family are engaged as partners in their care.
• Third, promoting effective communication and coordination of care.
• Fourth, promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease, a major killer in the United States, and something we can do a lot about.
• Fifth, working with communities to promote the wide use of best practices to enable healthy living.
• And sixth, making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.  It’s one thing to have a successful intervention, but it’s another thing entirely to spread, adapt and adopt it – we’re not doing that very well yet.

So the National Quality Strategy is designed to be an evolving guide for the country as we move forward with efforts to measure and improve health and health care quality.  And as you see the focus of these priorities, I think you can tell how well-aligned they are with nursing’s focus on health and health care.

As we proceed with implementation of the ACA, we will use the strategy’s aims and priorities to monitor and track our progress.

The National Quality Strategy then, is a document that sets a foundation for all our quality efforts.  I strongly encourage you to read the report that announced the strategy and familiarize yourself with its content.  You can find it through healthcare.gov.

Let me wrap up by restating what I’ve just told you: nursing is ‘front and center’ in much of what is supported and created by the ACA. 

And nursing, as a profession, is responding to today’s challenges.

We know that nurses in the United States grew to a new high of 3.1 million in 2008, and for the first time in three decades, the youngest population of nurses grew, which is helping to restock the pool of RNs.

Encouragingly, HRSA’s 2008 National Sample Survey of Registered Nurses, the preeminent source of statistics on trends over time, found that the RN workforce is gradually, slowly, becoming more diverse. In 2008, 16.8 percent of nurses were Asian, Black/African-American, American Indian/Alaska Native, and/or Hispanic.  That’s an increase from 12.2 percent in 2004.

We still have a way to go in terms of graduating nurses, but we’re moving in the right direction. 

And in terms of nurses in prominent roles in the Obama administration, I can’t let you leave thinking that I’m the only one.

I am the first nurse to run HRSA, and while I’m the most senior nurse in this administration, I’m not the only one in a senior position.  It is gratifying to consider that there are, perhaps, more nurses in senior executive positions in the federal government today than at any other time in memory. 

Marilyn Tavenner, also a nurse, is the principal deputy administrator of the Center for Medicare and Medicaid Services. 

And at HRSA, I’m pleased to report that nurses are well-represented among my senior advisors:

• Our #2 billion HIV/AIDS Bureau is run by Dr. Deborah Parham-Hopson, a nurse.
• The Associate Administrator of our Bureau of Health Professions, Dr. Jan Heinrich, is a public health nurse who has long been a supporter of nurses in primary care and advanced practice.

• Our Office of Global Health Affairs is led by Kerry Nesseler.  Kerry also is the chief nurse of the U.S. Public Health Service.
• Dr. Denise Geolot directs our Office of Strategic Priorities, which examines and responds to emerging health issues.
• And the director of our Division of Nursing, Dr. Julie Sochalski, chairs our National Advisory Council on Nurse Education and Practice, which annually provides recommendations to the Secretary of HHS and the Congress on policies and strategies to advance nursing workforce development.

I’m proud to work alongside these fine nurse leaders and alongside all of the committed health professionals that make up the HRSA staff.

All of them spend incredible amounts of time and energy working to implement the Affordable Care Act because they, like me, are optimists who believe in its promise to improve health care in this wonderful land we all share.

I’d like to leave you with a quote attributed to the late New York Senator and scholar, Daniel Patrick Moynihan.  He said, “You’re entitled to your own opinions; you’re not entitled to your own facts.”

What I’ve just told you in this speech about the Affordable Care Act may not be what you hear on talk radio or cable tv shows.

But they sure as heck are the facts.

Thank you.  I’ll be happy to take any questions you may have.