Remarks to the Uniformed Services University of the Health Sciences, Graduate School of Nursing

---

By HRSA Administrator Mary K. Wakefield

October 29, 2013
Bethesda, Maryland

Thank you Dr. Rice (Charles Rice, President, Uniformed Services University). Good morning, everyone. I am very pleased to join you in celebrating 20 years of nursing education and leadership development at the Uniformed Services University of the Health Sciences. The high caliber of the nursing program in this university is widely recognized, and I think that the success of the Graduate School of Nursing can be attributed, in no small part, to 20 years of tremendous leadership – from founding Dean Faye Abdella, the first nurse Deputy Surgeon General, to your current dean, Ada Sue Hinshaw.

And, of course, to outstanding faculty, one in the room I know personally, Dr. Pat Deleon. A long-standing supporter of the nursing profession and someone who 25 years ago – yes, it’s been that long, Pat – was the best mentor I could have had when I was a fresh-faced nurse coming off the northern plains with painfully limited knowledge of health policy. With all the patience in the world, he walked me through what I needed to know year after year, when we both worked on Capitol Hill.

And I think Pat is emblematic of many of the faculty who have taught in this university – with tremendous knowledge, support and high expectations for the students in their midst, whether those students are in a formal classroom or in a work setting.

Clearly, through the administration’s and faculty’s efforts – and as a result of this university’s signature approach to education and research – the nursing programs here have become an important resource for the health of the military and for the nation’s public health. Having as a primary focus the education of members of the military to influence health and health care for those in active duty, that’s a mission and a contribution that I believe is almost unparalleled in its importance.

So whether in its first graduating class, or the graduating class of next year, across these 40 years, nurses educated here garner both significant respect and also significant expectations of their future contributions.

In fact, from where I stand, you comprise a pretty very elite crowd, one that prompts just a tinge of envy. Because there was a time, now decades ago, when I aspired to be one of you. In fact, while still in my undergraduate nursing program, I made a bid to join the Air Force. It was the first time I started to realize that academic performance matters.

But rejection from high places is probably good for the soul, and for stoking one’s humility. And while that outcome at the time wasn’t my preference, and it clearly sent me down a different path, I’ve nevertheless always held the highest regard for nurses in service to the U.S. military.

Instead, as was mentioned, I’m the first nurse to lead the Health Resources and Services Administration – HRSA. As an aside, I was appointed to this position by the President in part because I am a nurse, and the experience I draw on most every day is my education and experience in our shared profession.

As the administrator of HRSA, some of the focus of my work certainly intersects with yours, as one of HRSA’s strategic aims is to help field a competent and adequate health care workforce that is well prepared to provide quality services in a rapidly changing health care system – a focus shared by USUHS – with primarily different patient and community populations in mind but with the same overarching aim.

So I’ll spend my time with you telling you a little more about HRSA, an operating division of HHS located just a few miles from right here, and about the focus we have on both education and health care delivery, and what we’re doing to strengthen the health care workforce and health care delivery. And no doubt you’ll hear a shared agenda between what you and we focus on.

At HRSA we operate over 80 programs, and directly or indirectly there is a focus on health care workforce that can be found in almost all of them, and it’s a focus that I’ve worked hard to strengthen.

With a budget of $8.1 billion, HRSA and its 3,000 partners across the country help to strengthen access to care, help build a diverse and culturally competent health care workforce, and improve health equity.

Perhaps our most well-known program is one that supports the nationwide network of health centers, which deliver primary and preventive care to 21 million patients at more than 9,000 underserved areas throughout the country. Health centers provide services to anyone who seeks health care there, with fees adjusted based on patients’ ability to pay.

Many of these centers employ primary care providers who join the National Health Service Corps and commit to practice in these underserved areas in exchange for student scholarships and loan repayments. HRSA oversees all of the NHSC scholarship and loan repayment awards and helps place these individuals in underserved areas.

NHSC clinicians include nurse practitioners, nurse midwives, physicians and physician assistants; dentists and dental hygienists; and mental and behavioral health professionals. Eight out of 10 health care professionals who join the program continue to practice in the same underserved communities after their contracts expire. I’ll say more about these two programs for which we have responsibility in just a minute.

HRSA operates a similar scholarship and loan repayment program strictly for nurses – called the NURSE Corps – currently made up of over 2,500 nurses practicing in underserved areas throughout the country.

HRSA is also responsible for a broad range of health professions education programs.

Other important HRSA programs include:

• The Maternal and Child Health State Block Grant Program, which helps states deploy trained health care providers to care for more than 44 million women, infants, and children, including children with special health care needs. Facets of this program touch the lives of about one out of every six women who give birth in the U.S. and their infants.
• The Ryan White HIV/AIDS Program, which supports the delivery of quality care and life-sustaining medications to more than half a million low-income and uninsured people living with HIV/AIDS.
• And programs through the HHS Office of Rural Health Policy, which help support providers in rural and isolated areas improve patient care with the use of telehealth, telemedicine, and health IT.

We also support the poison control centers, organ donations and procurement across the country, and the national practitioner data bank – the latter not exactly a favorite of a lot of health care providers – among a number of other programs.

Well, our agency has three strategic aims, and educating and training our health workforce to meet new patient demands and respond to a changing health care delivery system is one of them. This is particularly critical as individuals and families gain access to affordable health insurance through the Affordable Care Act, and as Affordable Care Act provisions recalibrate features of the health care delivery system – some of that work being underway through HRSA.

One of the most challenging tasks for all of us involved in supporting current and future members of our health care workforce – those of us in the civilian and presumably the military as well – is to identify and implement the best ways to reset the training and deployment of our health care workforce so that health care providers are exquisitely well-positioned to meet increased demand for certain health care services and to lead changes in our respective health care delivery systems.

Obviously, as the largest workforce segment of our health care system – 2.8 million – nursing is an important discipline to leverage in efforts to evolve and adapt health care to the nation’s changing demographics and projected increases in demand for services.

Just to illustrate the point about the relationship between one provision of the ACA and supply and utilization of the nursing workforce, a research study published earlier this month begins to quantify the significance of the ways that nurses improve care in the hospital setting.

The study found that hospitals with higher nurse staffing had 25 percent lower odds of readmissions among Medicare beneficiaries compared to similar hospitals with lower staffing. In the current practice setting, with the ACA tying hospital reimbursement to outcomes like patient readmissions, recognizing that this is just one study, the finding nevertheless is not insignificant.

So, the study demonstrates that higher nurse staffing levels may improve the quality of care patients receive in the hospital setting, as well as protect against a reduction in reimbursement rates.

The role of nurses is clearly evolving, and nurses are increasingly taking on leadership roles across the entire spectrum of health care. This isn’t new, and the Institute of Medicine-Robert Wood Johnson Foundation report on The Future of Nursing reinforced this fact by envisioning nurses as key leaders for building better health care in America.

The thrust of the IOM report – having nurse leaders at all levels and all sectors of health and health care, from academia to community health to public policy and elsewhere – is neither redundant nor is it a nicety, it’s absolutely essential for the efficient and high-quality functioning of health care delivery and for the nation’s health.

This work requires not just adequate numbers of nurses, but also a nursing workforce that has the competencies and skills to both help design and also to function within redesigned health care systems.

So the focus at HRSA is on both knowledge and skills but also on nursing supply.  As nurses increasingly step up to become health care leaders and take on more critical roles in health care delivery, it is important that we not lose sight of continuing to grow the workforce as well.

Through our programs at HRSA, we focus on supply, distribution to underserved areas, diversity in the workforce, competencies, and data about nursing and other health care disciplines.

For example, with regard to nursing supply, the HRSA 2013 Nursing Workforce Report found, among other things, that during the last 10 years, the number of first-time takers of the NCLEX with bachelor’s or higher degrees rose by nearly 135 percent, and that more than half of the RNs working today hold a bachelor’s degree or higher. At the same time, the number of RNs grew by nearly a quarter – by half a million in 10 years.

While your target is primarily service to military populations, the Graduate School of Nursing at USUHS supports this growth in preparing graduates who contribute as part of the nation’s health care nursing workforce.

Our own efforts at HRSA to increase the number of primary care safety-net clinicians with a keen eye on the nursing profession – and to enhance the quality of their training and the distribution of data collection around this profession – these efforts received a substantial boost with passage of the Affordable Care Act in 2010.

This was no coincidence, and it was no coincidence that HRSA was given lead responsibility for implementing more than 60 provisions of the law.

Let me walk through some of the ACA programs that, among other things, also support the education and distribution of nurses. With funding through the Affordable Care Act, the health center program that I briefly mentioned a few minutes ago has added some 4,500 nursing positions since 2009. Right now, nearly 18,000 nurses work at health centers across the country, including 5,200 Advanced Practice Nurses. Of these, 4,678 are nurse practitioners and 564 are certified nurse midwives.

The ACA also extended substantial support to school-based health centers – which, as you know, rely heavily on RNs and advanced practice nurses – to ensure that children can stay healthy and are more ready to learn at their highest potential.

The ACA also markedly boosted the National Health Service Corps program, which now includes more than 1,600 Nurse Practitioners – nearly twice as many as there were four years ago – and the NURSE Corps, which supports over 230 Nurse Practitioners.

And, in the area of maternal and child care, the ACA created the Maternal, Infant, and Early Childhood Home Visitation Program, which is putting more health care “boots on the ground” in underserved and at-risk communities.

Under this effort – better known as the Home Visiting Program – nurses, clinical social workers, and lay workers who share cultural backgrounds with their neighbors work with pregnant women and young children in their homes in high-risk communities. There, they provide early counseling and intervention services using evidence-based models that are known to improve health outcomes.

As an aside, there’s often talk of evidence-based practice, but the ACA also has many examples of evidence-based policy, and this particular program is one of them. More than 500 nurses are currently working in this program.

So as you can see, the nursing profession as a whole is taking on increasingly important roles and responsibilities in the primary health care system, and the Affordable Care Act supports and relies on the profession.

Beyond the immediate impact that the Affordable Care Act has had on the number of primary health care clinicians, including nurses, the law created tremendous opportunities to improve training for nurses and others in the primary care workforce.

For example, the ACA directed $15 million to nurse-managed health clinics, which are managed by advanced practice nurses and affiliated with schools of nursing. These clinics train new nurses while delivering primary care to vulnerable populations, often for example located in places like public housing.

The ACA also directed $31 million to prepare more primary care advanced practice nurses and $200 million for graduate nurse education programs that prepare APNs for roles in coordinating care. So you see this targets support in two areas – the clinical focus on primary care, and the skills and knowledge that come with graduate degrees.

Since FY 2010, HRSA has awarded $22 million in grants to schools of nursing and medicine, physician assistant programs, nursing centers, academic health centers, and other entities, giving priority to efforts to recruit and support military veterans who want to pursue careers as advanced practice nurses and PAs.

Included in this $22 million is a $2.8 million investment we made just last month to help veterans advance in nursing careers. Across the programs we’re supporting over four years, we expect these grants to enable more than 1,000 veterans to obtain baccalaureate nursing degrees. This is part of an increased effort to support our veterans.

And HRSA is now giving additional review points to applicants for workforce-related grants that detail strong veteran recruitment, retention, and mentoring activities. This is in large part because of the President’s interest in federal programs reaching out to support our veterans, and not just through the VA.

With support from the ACA, we are also strongly focused not just on supply but also on the interplay between training and its impact on the quality of health care, on cost-effectiveness of care, and on patient outcomes.

To leverage the impact that training has, emerging clinicians must be taught core competencies – for example, how to practice as team members across health care settings, or how to assess and apply clinical evidence regarding treatment options to facilitate care coordination so that care is cutting-edge, high-value, and evidence-based.

Our emphasis on team-based care recognizes that there are gaps in health care between settings and among health care providers. And these gaps can put the health of patients at risk while driving inefficiency and increasing costs.

In the context of our evolving health care delivery system, which is transitioning from a model dominated by acute care to one that more robustly embraces primary care, prevention, and care coordination, nurses should be able to function as key players in complex delivery of high-value coordinated care.

So at HRSA, we are working to catalyze the delivery of health care by provider teams through interprofessional training – people working across disciplines and across settings to ensure that health care services are seamless, coordinated and collaborative – no gaps, no inefficiencies. That, by the way, sounds a lot easier than it is.

I should point out that our approach here applies not only to students but also to faculty. Educators who are trying to redesign medical residencies to train residents in new models of care – such as Patient Centered Medical Homes – need new skills, too. And understanding these needs should inform faculty development programs to achieve the crucial mission of training the future workforce. That’s exactly what we’re doing with some of our programs.

With this focus on interdisciplinary care at HRSA, we have developed a set of core sub-competencies for interprofessional training and practice. The competencies were produced through extensive partnerships with the Robert Wood Johnson and Josiah Macy Jr. foundations, the Interprofessional Education Collaborative, and the American Board of Internal Medicine Foundation, and others.

As an aside, people don’t always think of the federal government working in partnership with foundations, but we do.

In order to bring a very precise focus to this combination of interprofessional education and team-based care, HRSA awarded a grant to the University of Minnesota Academic Health Center last year to serve as the site of a new National Center for Interprofessional Practice and Education.

This five-year, $4-million initiative is designed to support the transformation of the prevalent siloed healthcare delivery system into an integrated health system of coordinated, collaborative, team-based practice that becomes the new national norm. Fairly ambitious agenda, isn’t it? But with our partners, that’s what we’re working toward.

Through investment from a number of private foundations (Macy, RWJ, and the John Hartford and Gordon and Betty Moore foundations), this $4 million of federal funding we put on the table has been leveraged into over $12 million in projects and activities, including the establishment of a clear organizational model in pursuit of the often-referenced Triple Aim – better health, better care, and lower cost – by establishing a business case for the effectiveness of interprofessional, team-based care and its impact on population health.

So, in one way or another, the ACA brings life to not only the competency of working in interdisciplinary teams, but also to other core competencies that have been advocated by the IOM, including a renewed emphasis on patient-centered care, employing evidence-based practices, applying quality improvement science, and harnessing technology.

Looking forward, new models of care are being supported, and they will continue to emerge. And one excellent place to look for the future of care delivery is at the ACA-funded Center for Medicare and Medicaid Innovation. One of the Innovation Center’s latest projects is the State Innovation Models initiative.

The 25 states that received awards are required to, quote: “use the full range of their executive and legislative authority to facilitate and support new health care delivery models.” And they are asked to consider – among other things – changes to state-based health care workforce policies on training, professional licensure, and scope-of-practice statutes.

So as you can see, there are clear and direct links between our health care workforce training activities at HRSA, the support through the Affordable Care Act for a new paradigm for the training, education, and deployment of future generations of advanced practice nurses – and indeed of all clinicians, whether civilian or military.

Let me end with just a comment on yet another area where your interests and ours intersect, and that is research. HRSA is not NIH, of course, but we have a significant research footprint in the field of health services, and you may find some of it useful in your own research.

HRSA performs research and publishes data and reports in a number of areas that are useful for improving our understanding of health care needs, services delivery, or training.

For example, each year, health centers report on a vast amount of data on expenses, services provided, patients treated, and more. This data, and much more, is available online through the HRSA Data Warehouse, which provides an array of visual and interactive tools for searching, accessing, viewing, and displaying data.

The current Administration is the first to make this data available to the public for free at hrsa.gov.

Another component of HRSA’s research portfolio, one that was established with the passage of the Affordable Care Act, is the National Center for Health Workforce Analysis. The Workforce Center is building a data reservoir to track the supply, demand, and need for health workers – and to make that information available to influence and shape policy making and workforce investments.

A number of the Center’s products include information about the nursing practice, including publication of data on the 2012 National Sample Survey of Nurse Practitioners, which aims to provide accurate national estimates of the nurse practitioner workforce in a number of dimensions, such as education, certification, and practice.

We surveyed nearly 13,000 randomly selected licensed NPs and achieved a 60.1 percent response rate. The National Center is currently analyzing the data and developing reports that will be available to the public at no charge on our web site.

We have also made great strides in increasing the accessibility of our data to the public, and you may find the Area Health Resource File – yes, we call it “arf” – especially useful. The new AHRF is a county-level health resource information database that compiles data from over 50 different sources and has over 6,000 variables, including data for over 20 health professions.

This coming month, the AHRF for the first time will include state and national level data on health professions. It is available for free at arf.hrsa.gov.

Another important initiative of the Workforce Center that some of you may know about is the building of a Minimum Data Set, which is working toward the ability to compare health care workforce data across states. This is something researchers and policy makers are currently lacking and could also inform policies and investments.

So there are many different ways to use our programs for research, and if it’s not available online, you can always contact HRSA program staff to help you.

The investments and activities I just mentioned are all very important, but there are even more opportunities and challenges ahead for nurse leaders. Nurses today find themselves at a historic juncture in the evolution of health care delivery, a time when they can play a pivotal leadership role.

In closing, I very much appreciate the opportunity to join you in celebrating 20 years of training nurses, nurse educators, and nurse leaders to improve the health and health care of the people you serve, and who serve all of us.

At HRSA, we look forward to working with you on our shared commitment to the future of nursing and our health care workforce and the health of the nation, including of our active duty military and our veterans.

Thanks again for the opportunity to speak with you today, and congratulations again on 20 years of national leadership in nursing education.