AONE: Nursing Care's Long Reach Gets Results

At the American Organization of Nurse Executives 2016 annual conference, nurse leaders share how they are expanding nursing care across the care continuum, to the great benefit of both patients and institutions.

The official theme for this year's American Organization of Nurse Executives annual conference was, "Inspiring leaders," but based on the sessions I attended, an alternative theme could have been, "Nurses: Everywhere You Want to Be."

What I mean by this is that nursing care is no longer strictly task-based and delivered at the bedside.

Instead, nurses have become integral in achieving the goals of the new healthcare environment—value-based care, improved patient outcomes, greater access to healthcare—and they are working their magic throughout the care continuum. Nurses can be found in the C-suite, at the unit level, in the ambulatory setting, on boards, and in the community.

Read on for some of the ways nurses are delivering care across the healthcare landscape.

The Surplus Project

The poster presentation, "Surplus Project: Serving Food Insecure Populations Through a Leadership Development Program," detailed how Jennifer M. Grenier, RN-BC, MSN, nurse director, telemetry at not-for-profit Rush Oak Park (IL) Hospital, was able to provide 10, 238 meals to an area food pantry over the course of four months by repackaging leftover food the hospital was going to throw out.

Not only was she able to address the needs of those in the community facing food insecurity, but she was also able to provide healthcare screenings at the food pantry on donation days with help from RNs on The Surplus Project team.

While significantly different than reading cardiac rhythms and administering medications, she still used her nursing skills of critical thinking and assessment to identify a community health issue and to develop a solution that affected the health of a patient population.

The Nurse Leader's Role in Care Coordination and Transition Management

Navigating the healthcare system can be tricky for patients, especially those with co-morbid conditions and multiple providers. Gaps in care, such as medication errors or missed follow-up appointments, can occur when patients' care plans aren't well communicated. As a result, patients may end-up experiencing avoidable complications and costly hospital readmissions.

Improving care coordination and transitions isn't just the domain of RNs with designated care coordination roles, says Mary Beth Kingston, RN, MSN, NEA-BC, executive vice president and system chief nursing officer at for-profit Aurora Healthcare in Milwaukee, WI.

"Many times we think of care coordination as specific RN coordination roles, and there are many of them, and they've proven to be very effective in terms of managing health and improving outcomes," she says. "But focusing on inpatient nurses is equally important because it's recognizing the fact that all nurses have care coordination roles."

This includes nurse leaders in acute and post-acute care settings which is why AONE and the American Academy of Ambulatory Care Nursing collaborated to issue a joint statement.

Outlined in the statement and discussed during the session are six principles nurse leaders can follow to help create a care coordination process that "includes all staff, key stakeholders and nurse leaders across the continuum of care:" 

1. Know how care is coordinated in your setting
2. Know who is providing care
3. Establish relationships with multiple entities and individuals who can work together to improve care coordination and transition management systems
4. Know the value of technology, its impact on workflow, and the roles of care coordination team members
5. Engage the patient and family
6. Engage all team members in care coordination

As Kingston points out, nurse leaders play a vital role in creating the scaffolding that supports care coordination at an organization.

"I'm not a care coordination expert," she says, "but what I do know is, that as a nurse leader, I really need to understand what's happening in my organization because I'm often in the role of advocating, of translating, of integrating, and of decision-making regarding care coordination technology."

The BSN-Prepared Nurse Navigator in the Ambulatory Setting

Through years of research, University of Pennsylvania nurse researcher Linda Aiken, RN, PhD, FAAN, FRCN, has found that hospitals with more BSN-prepared nurses have lower mortality rates and fewer adverse patient outcomes compared to those with less BSN-prepared nurses.

At Bon Secours Health System, a not-for-profit Catholic system headquartered in Marriottsville, MD, nurse leaders are seeing the value of BSN-prepared nurses in the ambulatory setting as well.

"When allowing our baccalaureate-prepared, professional nurses in the ambulatory setting to work to the fullest extent of their education and training, we have achieved a significant clinical and financial return on investment," says Liana Orsolini, RN, PhD, ANEF, FAAN, care delivery and advanced practice system consultant at Bon Secours Health System.

Angel Daniels, RN, MSN, CCN, clinical manager, clinical operations and medical home department at the health system explains that by using BSN-prepared nurse navigators, Bon Secours has been able to generate revenue to the tune of $1 million annually in the areas of complex case management, annual wellness visits, and transitions of care.

"By allowing the nurse navigator to complete the annual wellness visits, that generates revenue because it allows the providers to increase capacity and open their schedules to see more patients, "she says.

Nurse navigators have also contributed to cost reduction by maintaining a 1-2% readmission rate for the system.