Remarks to an Evidence-Based Nursing Research Conference

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by HRSA Administrator Mary K. Wakefield

October 28, 2011
Salt Lake City, Utah

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Hello, everyone, and thanks for inviting me to join you today.  I’m especially pleased to share the podium with a nationally recognized nurse leader, Linda Burnes Bolton.

And I’m particularly pleased to talk with you as the Administrator of Health Resources and Services Administration -- and as a nurse colleague.

I think it sent a powerful message about the value of nursing’s expertise that President Obama appointed a nurse to head a $9.7 billion agency like HRSA.  While I’m privileged to be that nurse, what is most important is that the position is filled by a nurse for the first time in the history of the agency.

The President recognizes nursing as a source of expertise to help guide key health care programs and policies, and when we think about the future of nursing, it’s these sorts of breakthroughs that help set the stage for the next generation of nurses and the next set of contributions from the profession.

That recognition is also reflected in the views of the HHS Secretary Kathleen Sebelius, my immediate boss.  To illustrate the point, she said a couple of weeks ago in an address to a nursing group that “the history of improvements to the American health care system is a history of nurses leading the way.”

Those aren’t my words, they’re hers.

She added that “over the next few years, we’ll face a pivotal choice about the future of American health care.  And you” – meaning nurses – “can play a big role in making sure we choose wisely.”

Again, she acknowledges the significant impact nurses can make – when they choose to – in American health care. 

In those remarks, of course, the Secretary was referring to the future of American health care embodied in the Affordable Care Act – the health care reform law that President Obama signed last year, a law that writes a new and important chapter in health care across America.

And my remarks today are about the future of the nursing profession and the people nurses care for, in the context of this new law.  The law recognizes and codifies the value of the nursing profession by boosting funds for nurse education and training, and by crafting important and expanded roles for advanced practice nurses in primary care delivery.

The law, for example, envisions nurses playing key roles in health care teams, which are essential components of new health care delivery models advanced by the ACA.  These new models include Medical (or Health) Homes and Accountable Care Organizations.

And while you’re not necessarily reading about the accomplishments I’m about to share with you in your morning newspaper, already the Affordable Care Act is showing us that a better health care system is possible.

For example, for those of you whose practice or research touches young adults, in the last month we’ve learned that more than a million young people now have health insurance because of a provision that allows them to stay on their parents’ health insurance plan.

While we all know that 20-to-26-year olds are a pretty healthy population overall, anyone in that age can be one illness or one accident away from very high-cost care.  But from now on, those worries are gone.  That wasn’t true two years ago.  But it’s true now, and it will be true for all the young people that follow.

On another front, the law’s Patients’ Bill of Rights has ended many of the worst abuses of the insurance industry.  Lifetime caps on benefits are now banned; before passage of the ACA the caps on benefits often meant that people lost health coverage when they got very sick – just when they needed it most!  Also banned is the practice of insurance companies canceling people’s coverage because of an accidental paperwork mistake.

For those of you who might be or aspire to be pediatric nurses or school nurses, the future for many of your patients changes, too.  Already effective now, kids can no longer be denied coverage because of pre-existing conditions like asthma, diabetes or autism.  By 2014, discrimination against pre-existing conditions will end for all Americans.

And, since the ACA was signed into law, more than 19 million Medicare beneficiaries have gotten at least one free preventive service like a cancer or diabetes screening with no out-of-pocket payment required.  It’s about keeping our elderly healthy or mitigating illness as early as possible.

And starting next year, women will receive free preventive health services that include screening for gestational diabetes, HPV, and a range of conditions associated with poor birth outcomes, along with breastfeeding support and domestic violence counseling.

Across HHS, we’ve been busy: what I’ve described is a lot of progress in a year and half.  And you notice the provisions I’ve just discussed focus on keeping people healthy and preventing illness, rather than waiting for the progression of diseases.  It’s an orientation valued by seniors in undergrad nursing programs, and it’s valued, too, obviously, by the Administration.

And there will be more progress:  we’re still working to implement the full legislation.

For those of you who may not know exactly what HRSA does, let me give you a short summary of the world that I, as a nurse, live in.  At HRSA, we use our $9.7 billion budget to improve access to health care services for people who are uninsured, medically vulnerable and geographically distant.  For example:

• HRSA’s community health center network treated 19.5 million patients last year at more than 8,100 service delivery sites.  In Utah, we support 48 health center sites and about 630 jobs at those sites.  It’s important to note that almost 16,000 nurses – including 4,300 in advanced practice – work at health centers across the nation, and since the ACA invests  $11 billion over five years to expand health center operations, the number of nurses there will grow.  So when you look to nursing’s future, you can certainly look there for opportunity.
• Our National Health Service Corps places primary care providers in underserved areas for at least two years in exchange for paying down their student loans.  Earlier this month, we announced that the number of NHSC clinicians had reached 10,000, almost three times the number when President Obama took office.  I’m really excited to say that with the Obama Administration’s unprecedented support, the number of nurse practitioners in the Corps has more than doubled to 1,667, and more than 200 nurse midwives are Corps members.  In Utah, there are 124 NHSC clinicians from several disciplines.
• In addition to helping deploy providers to our neediest areas, HRSA also strengthens the nation’s health care workforce by giving financial support to colleges and universities for training and curriculum development, scholarships and loan repayments for students in the health professions: nursing, medicine, physician assistants, allied health and so on.
• Our Maternal and Child Health block grants to states pay for screenings, counseling and immunizations that reach 6 of every 10 pregnant women and their infants.  In Utah, these MCH investments total almost $15 million, which also pays for programs helping kids with special health care needs and the training of MCH providers.
• We administer the Ryan White HIV/AIDS Program, whose 900 clinics provide top-quality care and life-sustaining medication to more than half a million low-income and uninsured people living with HIV/AIDS.  Utah receives $10 million annually in Ryan White funds.
• We also house the Department’s Office of Rural Health Policy – important to states like Utah – which bolsters rural hospitals and coordinates coalitions of rural providers.  Utah receives $5.5 million from HRSA’s rural health programs.  And the Office supports the expanded use of telehealth to connect people to distant providers through monitoring devices and teleconferencing.
• Finally, we oversee the nation’s Poison Control Centers, federal organ transplant efforts, and the National Vaccine Injury Compensation Program, among other health system activities. 

We do all this, and more, through our management and oversight of 80-plus different grant programs.  The services authorized in these programs are delivered by our grantee partners in 3,000 state and local government entities and community-based organizations.  So wherever most of you work as nurses, we may well be connected – your work and mine.

A moment ago I told you that the Affordable Care Act assigns considerable responsibility and opportunity to nurses.  The new home visiting program is a prime example of that.

The Act authorized $1.5 billion over five years to create and implement a new Maternal, Infant, and Early Childhood Home Visitation Program.  Under this model, nurses, social workers and others visit pregnant women and their families in their homes in high-risk communities.  There, they provide counseling and intervention services that – based on evidence – are known to have improved health outcomes.  This isn’t the only ACA provision that pivots off of evidence.  Evidence-based policy is, from my perspective, as important as evidence-based practice.

States apply 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.

If you step back and think about it, high-risk mothers and infants are wrapped in state-of-the-art technology while in acute-care settings, but too often across the country that support melts away when they leave the hospital.  That isn’t in the interest of the infant and it isn’t in the interest of holding down health care costs.

Last year state-level grantees, including Utah, conducted statewide, community-based needs assessments.  These assessments collected data on premature births, low-birth weights, infant deaths due to neglect, and other indicators of at-risk prenatal, maternal, newborn or child health.

This year, the Home Visiting program got fully under way nationwide, and just last month, we announced the award of $224 million to state agencies to implement the program.

You might be interested to know that this is another ACA provision that recognized nursing expertise, because it was a nurse, Harriet Kitzman – alongside developmental psychologist David Olds and others – whose research showed that teaching low-income pregnant women about prenatal health and childhood development could lead to dramatic improvements in outcomes.  That research informed the development of the Home Visiting Program.  International research tells us that countries with nurse home visiting programs have lower infant mortality rates than the United States.

We know that it makes more sense to provide preventive care sooner, rather than more costly clinical care later.  We know that investments in primary care result in fewer expenses in the end – fewer clinic visits or trips to the hospital.  What’s the best way to manage a chronic illness?  Prevent it in the first place!  President Obama agrees – and that pro-prevention theme runs throughout the Affordable Care Act.

Nurses’ value in America’s health care future is seen in other Affordable Care Act investments.

For example, the Act allots $15 million to create new Nurse-Managed Health Centers, which are run by advanced practice nurses and affiliated with schools of nursing.  More than 250 existing clinics provide training opportunities for nurses and other health professions students while delivering community-based, primary care to vulnerable populations, like public housing residents.  The ACA funds are used to support innovative models, and this is clearly one.

Earlier I mentioned the ACA’s expansion of the community health center system.  Included in that is an investment of $200 million to expand the reach of school-based health centers, which allow even the most disadvantaged kids to get care before major health problems take root.  Nurses, of course, have been the backbone of school-based care for years. 

In addition, the ACA authorizes millions of dollars to support nursing education and practice.

HRSA’s Nursing Education Loan Repayment Program has seen its budget more than double since 2009 to almost $94 million today.  Under this program, RNs who opt to work for two years in a facility with a critical nursing shortage can get 60 percent of their education debt paid off.  The Affordable Care Act makes nurse faculty eligible for this program for the first time.

The law also provided $31 million to 26 schools of nursing to boost the number of Nurse Practitioners and Nurse Midwives by 600 over five years.  From the perspective of the ACA, a nurse practitioner is a critically important provider.

Yet another program created under the 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.

This is just a partial list of the Affordable Care Act’s benefits for nurses.

You’ll notice that the last program I mentioned supports an increased role for nurses in care coordination.

Care coordination is a nursing-inspired and nursing-led issue.  And it is something that impacts all of the problems that afflict American health care:  increasing costs, questionable care quality, and compromised safety.

The Affordable Care Act recognizes that better care coordination is at the core of efforts to improve health care quality and safety.  By making greater use of patient-centered medical (or health) homes, Accountable Care Organizations, value-based purchasing and other strategies, we can cut hospital readmissions and reduce health care-caused infections.

We know, too, 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 results in lower hospital readmission rates, higher quality outcomes for patients, and lower costs.

Coordinating care means building teams of professionals that cross health care disciplines and roles.  This type of care requires health professionals to learn together with the aim of, together, delivering high-quality care.  Rather than training the next generation workforce in health professions silos, interprofessional education needs to continue to push out boundaries, creating academic and clinical experiences for students that advance the goal of health professionals working collaboratively to provide patient-centered care.

Our focus on team-based care and interprofessional education comes from a realization that the way health care is currently delivered results in compromised care quality.

As Secretary Sebelius told the Senate Finance Committee earlier this year:

“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.”

The Secretary clearly knows what nurses know: there are gaps in health care between settings and among health care providers.  And these gaps put the health of patients at risk while driving inefficiency and increasing costs.  We cannot afford to continue this status quo.

Our view at HRSA – with our responsibility for many health workforce programs – is that the Secretary articulated a problem which is partially amenable to how we educate and deploy our health care workforce.  Under my direction, HRSA has become deeply involved in efforts to join with partners across the health care spectrum to push forward the concept of interprofessional care and education.  Here’s how we’re engaging this agenda, with the help of some friends.

In February, HRSA convened a meeting in partnership with the Macy Foundation, the Robert Wood Johnson Foundation, the American Board of Internal Medicine Foundation, and the Interprofessional Education Collaborative to establish the foundation for team-based care. 

That core group worked diligently with other experts from government, academia and foundations to develop an action plan.  In May, just three months later, I was happy to join them in announcing the development of a set of interprofessional competencies to be disseminated for use in health professions education and practice.

That achievement represents real, tangible progress in improving health care quality.  But it was only possible because the Affordable Care Act give us an opportunity for change unequalled in recent memory.  And it was only possible because leaders like President Obama and Secretary Sebelius encourage change and, in fact, expect us to innovate in delivering health care.

To support the drive to implement coordinated care, to make health care in this country more effective, and to improve patient outcomes, Secretary Sebelius in April launched a new national campaign called Partnership for Patients: Better Care, Lower Costs.  The Partnership has two goals: to keep patients from getting injured or sicker, and to help patients heal without preventable complications.

The Partnership identifies best practices in delivering safe and effective care – and helps them spread.  Already nearly 6,200 organizations have pledged their support.   That number includes University of Utah Health Care Hospitals and Clinics and more than 2,800 other hospital systems.

Fortune 500 companies have signed on, and so have some of the country’s largest health insurers.  It was no surprise to any of us that one of the first organizations to join was the American Academy of Nurse Practitioners.

And it should come as no surprise to any of you that from my vantage point, we believe that nurses should be playing a key role in making this initiative a success by developing, testing, and disseminating practice models that achieve our safety goals.

To find out more about the Partnership, to get answers to any other aspect of the Affordable Care Act that you’re interested in, and to inform the health care of your patients, health care for your families, or health policy, I urge nurses and anyone else interested in reform to visit the government web site at: http://www.healthcare.gov.

There’s another element of the Affordable Care Act I haven’t addressed yet: its emphasis on collecting better workforce data to inform policy decisions.  President Obama has been clear on this issue from the earliest days of his presidency.  In March 2009, he issued a memorandum to members of his administration that said the following: 

Science and the scientific process must inform and guide decisions of my Administration on a wide range of issues…

He then mentioned several categories in which science must lead, and the first listed was in the “improvement of public health.”

HRSA plays a role here through the Affordable Care Act’s creation of the new National Center for Health Workforce Analysis. 

The Center is expanding HRSA’s data collection and analysis capabilities to help policymakers and researchers identify health workforce needs.  We really need to be able to base policy decisions on objective, neutral data.  The Center will help us and all policymakers in that regard.

By the end of this year, we’re hoping to produce reports projecting the supply and demand for primary care practitioners; physician supply and demand by some specialties; and racial and ethnic diversity in the health professions.

Right now, we also are fielding a survey of nurse practitioners.  Because of the vital role they play in assuring access to primary care, we need to know more about how many there are, where they work, and the full range of their primary care services.

But health workforce planning is a shared federal-state responsibility – feds play a key, but not the only role – and we are working with HRSA-funded Area Health Education Centers, state Primary Care Organizations, and State Offices of Rural Health to strengthen states’ capacity to assess health workforce needs and target resources.

Let me wrap up by summarizing what I’ve discussed with you today: that nursing is “front and center” in much of what is supported and created by the Affordable Care Act. 

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.  There are now more nurses in federal management positions than ever before, including Marilyn Tavenner, the second-in-command at HRSA’s sister agency: the Centers for Medicare and Medicaid Services.

At HRSA, nurses are well-represented among my senior advisors:

• Our $2 billion HIV/AIDS Bureau is run by Dr. Deborah Parham-Hopson, a nurse.
• The leader of our Bureau of Health Professions, Dr. Jan Heinrich, is a public health nurse.
• Our Office of Global Health Affairs is led by Kerry Nesseler, who wears another hat as chief nurse of the U.S. Public Health Service.

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

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

I’d like to leave you today 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.