Nursing is often undervalued on paper. Some believe that reimbursement is the answer.
What is the value of nursing?
It’s an age-old question that circulates throughout C-suite meeting rooms in health systems across the country. And as of now, nursing often does not have a separate line item on many budgets, despite making up a large portion of the healthcare workforce.
To Katie Boston-Leary, director of nursing programs at the American Nurses Association (ANA), and a HealthLeaders Exchange member, that is a big part of why nursing is seemingly undervalued.
"I think a lot of it has to do with the fact that we're invisible in terms of how we contribute to the bottom line, particularly the financial well-being of institutions," Boston-Leary said. "We don't have a separate line item on the claim side and also on the reimbursement side."
In recent years, the idea of direct reimbursement for nurses has been making some headway.
The concept
According to the ANA, nursing costs are grouped in with patient room costs, and when the time comes for budget cuts, nursing is often the first to go. Direct-Reimbursement Nursing Model pilots "expand nursing practice and elevate the value of nursing through direct reimbursement for nursing care delivery, management, and coordination outcomes," says the ANA.
Anne Dabrow Woods, nurse practitioner and chief nurse of health learning, research and practice at Wolters Kluwer, says this model would impact both nurses and nurse practitioners, who provide primary care services but are not reimbursed in the same way that physicians are.
"They don't tend to see [nurse practitioners'] value as great as what a physician is, and all the research clearly shows that a lot of our care is equal to that of a physician," Woods said. "We're not saying we want to replace physicians, but we are saying we want to work collaboratively with them."
In terms of nursing, Woods argued that the lack of reimbursement communicates the lack of value for the work nurses do.
"Now as a nurse, it becomes really problematic if you're not getting reimbursed for the care you deliver … and you're lumped into that room and board charge," Woods said, "because it's very difficult to articulate the value that nurses bring to patient care in acute care settings or other settings if you can't reimburse."
Boston-Leary explained how in her experience as a chief nursing officer, she found that nursing was seen as an expense, which means it’s a liability and a cost that needs to be reduced.
"The way the system is set up, if organizations can reduce labor, particularly with nursing … and achieve excellent patient outcomes, that's the win," Boston-Leary said, "which doesn't help, because … nurses, in some cases, are going along with working [in] unhealthy work environments [with] unimaginable workloads."
"The harm is happening in the middle, which subsequently leads to issues with retention and ultimately recruitment," Boston-Leary said, "because word of mouth is a powerful thing."
Whether reimbursement is in the cards, Boston-Leary said, health systems are not properly valuing nursing.
"I think it's every institution's duty," Boston-Leary said, "it's more about the fact that there's a responsibility for every organization to understand how nurses contribute to the bottom line, because they do."
Reimbursement in practice
Many different reimbursement models could potentially be put in place if health systems decide to follow this strategy.
Woods said the first step is to look at nurses' impact on care and nurse-specific quality indicators. Some of the factors could include fall prevention, infections, and readmission rates.
The reimbursement process could be based on the model that physical therapists and occupational therapists use, according to Woods.
"They look at the overall patient acuity and they look at the time that is spent with the patient," Woods said.
Woods also suggested using the nurse equivalent to national provider numbers that others use to bill for their services.
"[Nurses] have a thing called a nurse's number, and you get that number when you pass your boards," Woods said. "If we could start associating the work of the nurse with their nurse's number, then you can start to really make a case for allowing nurses to bill for their services."
For payers, Woods said, change would likely begin at the federal level with the Centers for Medicare and Medicaid Services (CMS). This would provide a model for other payers.
"If we can get CMS to change, and there's been a lot of hesitancy for them to change up to this point," Woods said, "we would have a chance of changing other third-party payers."
Boston-Leary said there might be a pathway toward reimbursement in models that already exist for advanced practice nurses. However, Boston-Leary said, the system would have to undergo a total overhaul to make reimbursement a reality.
"Largely for all nurses, every single nurse getting directly reimbursed, I don’t know that the system itself and the people within the system have a tolerance for all that and the capacity for all that," Boston-Leary said, "because being set up for that in itself takes a lot."
To Rudy Jackson, senior vice president and chief nurse executive at UW Health, and a HealthLeaders Exchange member, the issue lies with making the concept a reality, especially in a time where the goal of many healthcare executives is to cut costs.
"Conceptually, the ability to recognize the care provided by nurses as a mechanism in reimbursement is incredibly interesting," Jackson said. "The challenge is [that] operationalizing a model such as this would require a complete restructuring of our entire healthcare reimbursement model."
Jackson also pointed out that there are already areas where nurses do get reimbursed.
"There are, in fact, certain skills completed by registered nurses that are reimbursable, such as Vascular Access Teams, however, not many," Jackson said. "There is an opportunity to look more aggressively at other skills provided by nurses."
Reimbursement would involve one process for submitting invoices or claims and getting reimbursed and another for denials and resubmissions.
“There's not much tolerance and ability and capacity for the system and the people within the system to make this happen," Boston-Leary said. "Not to mention, it's going to take a major reversal of the current processes and change for this to happen."
What about the cost?
As with any new program in healthcare, the first question on everyone's mind is how to pay for it.
According to Woods, the direct reimbursement process would not be taking money out of health systems.
"What we're saying is allow the nurses to get reimbursed for their work that they do,” Woods said. “And if they are employed by the healthcare organization, essentially that reimbursement goes back to that healthcare organization."
Reimbursement could act as a reinvestment in the health system, Woods explained, which would improve patient care along with recruitment and retention. If hospitals put a cost to the value of nursing, they would be in a better position to focus on developing nurses.
"If a nurse gets into a work situation and the situation is unsafe … the nurse is going to leave because its an uncertain work situation," Woods said. "If we can invest in our nurses and really articulate the value they bring, you're going to see better nurse retention."
To Boston-Leary, nurses do not always feel as respected as other members of the care team, and health systems need to understand how direct care nurses contribute to the bottom line.
"Understanding that piece, particularly when we do have to be more financially savvy as nurses and understand what things cost and how systems get reimbursed," Boston-Leary said, " adds to that piece of matter for nurses where they feel as if they are adding to the bottom line."
The alternatives
There are alternatives to reimbursement that could also demonstrate the value of nursing on paper.
To Jackson, the answer is that hospitals need to invest in nursing.
"Offer appropriate staffing ratios based on nursing's assessment of the care needed," Jackson said. "Leverage technology to support administrative tasks nurses are faced with."
Nursing is the single largest workforce in any hospital, according to Jackson, and so nurses must be included in leadership and decision-making processes.
"Nursing leadership should always be part of the senior leadership team with reporting responsibilities to the highest level of the organization,” Jackson said. "This ensures accountability and support."
Boston-Leary recommended looking at nurse-sensitive indicators, since nurses do have duties that directly impact outcomes. Health systems could look at the ROI when hiring new nurses in a similar way that they look at ROI when hiring new physicians.
"This is also a place where we can't afford to couch it in the space of soft dollars," Boston-Leary said, "because people hardly pay attention to soft dollars. It's more about hard numbers.”
CNOs should advocate for bringing in a finance partner who can crunch numbers and show how nurses are contributing to the bottom line, Boston-Leary said. Some health systems have even hired a nurse in the finance department to give input.
"I know this is going to be a struggle for most small critical access hospitals," Boston-Leary said, "but for the ones that can, they can lead the way to help set up the methodology for the smaller institutions and community hospitals that can't afford it."
Boston-Leary also recommended revisiting the metrics that health systems use to determine value.
One example is the average daily census, which only captures a certain number at a certain point in the day and doesn’t provide the full story. Another is productivity, which, according to Boston-Leary, is not the measure that people think it is.
"We should not be celebrating when nursing has 98% to 120% productivity," Boston-Leary said, "especially if you have a department that's not fully staffed. It may mean that you're overextending your people and it's impacting their wellness and overall health."
Health systems should also pay attention to the positions that tend to get cut when times get tough, since many of them are still necessary for a strong and resilient workforce, Boston-Leary said.
"I think these are all the things that require some research that CNOs can lead with the proper resources," Boston-Leary said, "and get the message out there, so that everyone sees it and understands how that could be applicable to where they are as well."
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Nurses must figure out how to burn bright and not burn out, says this nurse leader.
Shakira Henderson, PhD, DNP, MS, MPH, EMBA, IBCLC, RNC-NIC, was born and raised on a small Caribbean Island, where she says she developed a deep appreciation of academics from an early age. Dr. Henderson holds dual doctoral degrees, PhD and DNP, and master's degrees in business, public health, anatomical sciences, and advanced nursing practice with a sub-specialization in nursing education. She also holds undergraduate degrees in biological sciences, chemistry with a minor in microbiology and nursing.
Dr. Henderson now serves as the University of Florida College of Nursing’s sixth dean and chief administrative officer. Additionally, she is the associate vice president for nursing education, practice and research, and holds the position of system chief nurse executive for UF Health. She has worked for the past two decades to promote and implement sustainable integration of clinical research and clinical operations with an equity lens within health care systems. Her research focus areas include leadership, breastfeeding and global health.
On our latest installment of The Exec, HealthLeaders sat down with Dr. Henderson to discuss her journey into nursing, and her thoughts on trends in the nursing industry. Tune in to hear her insights.
Nurse leaders always have a lot on their plates, so since we are halfway through 2024, it's time for a mid-year check-in.
So far this year, the nursing shortage has remained top of mind for many CNOs, followed by the rise of new technologies such as virtual nursing and AI. Leaders have also been working to address nurse wellbeing and burnout, workplace violence, and innovative recruitment and retention strategies.
Here are three current top trends in nursing, according to Vicky Tilton, vice president, patient care services and chief nursing officer at Valley Children's Healthcare.
This virtual care model gives nurses time back at the bedside, according to this CNE.
On this episode of HL Shorts, we hear from Cynthia Latney, senior vice president and CNE at OhioHealth, and HealthLeaders Exchange member, about what the nurses' role is in the virtual care model at OhioHealth's new Pickerington Methodist Hospital. Tune in to hear her insights.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
CNOs should be ready to adapt to the evolving nature of healthcare while advancing nursing practice, according to this nurse leader.
Nurse leaders always have a lot on their plates, so since we are halfway through 2024, it's time for a mid-year check-in.
So far this year, the nursing shortage has remained top of mind for many CNOs, followed by the rise of new technologies such as virtual nursing and AI. Leaders have also been working to address nurse wellbeing and burnout, workplace violence, and innovative recruitment and retention strategies.
Here are three current top trends in nursing, according to Vicky Tilton, vice president, patient care services and chief nursing officer at Valley Children's Healthcare. Tilton said that these trends reflect ongoing efforts to advance nursing practice, improve patient outcomes, and adapt to the ever-changing needs and challenges in healthcare.
"It is essential to note that the nursing profession is diverse and dynamic," Tilton said, "and trends may vary based on factors such as specialty area, practice setting, and geographic location."
Technological integration
According to Tilton, advanced technologies such as AI, machine learning, robotics, and virtual care platforms are being increasingly incorporated into workflows. Tilton explained that nurse leaders should get ready to upskill nurses in digital literacy and specialized training programs to effectively implement these new tools.
"In 2024, nurses may see expanded roles in utilizing and managing these technologies to improve patient care, streamline workflows, and enhance clinical decision-making," Tilton said.
These new technologies have and will continue to impact nurse workflows and care delivery, and according to Tilton, they will have a significant impact on telehealth, remote patient monitoring, precision medicine, and genomics.
"As technology continues to evolve, healthcare organizations must adapt to harness its full potential and address associated challenges," Tilton said, "including data privacy concerns, interoperability issues, and disparities in access to digital health tools."
Mental health and wellbeing
The second trend that CNOs and other nurse leaders should focus on is the mental health and wellbeing of their staff.
The COVID-19 pandemic shined a light on the importance of having mental health resources and support systems, Tilton said, along with the need for building resilience among staff. CNOs should expand mental health training and resources for nurses as well as foster a culture of empathy and self-care.
"In 2024, nurses may play an increasingly vital role in promoting mental health awareness," Tilton said, "[by] providing psychosocial support, and integrating mental health screenings and interventions into routine care practices."
One way that CNOs can address mental health and wellness is through innovative staffing models. There are four new staffing models that Tilton said will revolutionize nursing: team-based care, flexible staffing, care continuity models, and telehealth nursing.
"Staffing models are expanding by incorporating specialized roles and leveraging advanced practice nurses to optimize care delivery and address workforce needs," Tilton said. "Contingency labor and role specialization to ensure operational efficiency and adaptability in meeting patient care demands are being leveraged as well."
Holistic patient-centered care
The last growing trend in the nursing industry is the focus on holistic and patient-centered care. Tilton explained that this might lead to the implementation of interdisciplinary collaboration models, such as nurse-led care teams, that provide comprehensive and personalized care. The goal is to address the specific needs of each patient.
"Nurses may prioritize care approaches that consider not only patients' physical health but also their emotional, social, and spiritual well-being," Tilton said.
The shift toward patient-centered care and consumerism is causing leaders to reshape healthcare delivery models, Tilton continued, and patients are more empowered to take an active role in their healthcare decisions by demanding transparency, convenience, personalized care, and access to care through technology.
"CNOs need to prioritize patient engagement, satisfaction, and safety by redesigning care processes, enhancing communication and education strategies, and incorporating patient feedback into quality improvement efforts," Tilton said.
Tilton also emphasized that CNOs are instrumental in fostering a patient-centered culture and in making sure that nurses are responsive to the diverse needs of patients and their families.
"By staying informed about these trends and proactively addressing the opportunities and challenges they present," Tilton said, "CNOs can effectively lead nursing departments, drive organizational success, and promote excellence in patient care."
As many health systems employ AI technology and virtual nursing, the idea of a "smart room" has come to the forefront.
HealthLeaders spoke to Cynthia Latney, senior vice president and CNE at OhioHealth, and HealthLeaders Exchange member, about the recently launchedPickerington Methodist Hospital, which is equipped with smart room technology that will create a different experience for patients and their families. Tune in to learn more.
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The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
The Chevron decision has the potential to impact public health and access to public healthcare, according to these organizations.
The United States Supreme Court recently overturned the long-standing Chevron deference doctrine, which held that courts should defer to agency interpretations of statutes that fall under the particular agency's purview, when the interpretation is reasonable, and the meaning of a statute is not made explicitly clear by Congress.
Hospitals and health systems will now potentially have to wait through legal challenges to regulations that were previously determined by the many federal agencies that influence healthcare.
An amicus brief, published in September 2023, warned that "overruling Chevron would have enormous impact on the administration of federal programs, including Medicare, Medicaid, and CHIP, that are critical to public health."
The brief was signed by the American Academy of Pediatrics, American Cancer Society, American Cancer Society Cancer Action Network, ALS Association, American Heart Association, American Lung Association, American Public Health Association, American Thoracic Society, Bazelon Center for Mental Health Law, Campaign for Tobacco-Free Kids, Child Neurology Foundation, Epilepsy Foundation, Muscular Dystrophy Association, National Health Law Program, Physicians for Social Responsibility, The Leukemia & Lymphoma Society, and Truth Initiative.
Here's what you need to know about how the Chevron decision will impact healthcare.
While prevention isn't always possible, there's still much to be done about workplace violence.
On this episode of HL Shorts, we hear from Mary Beth Kingston, executive vice president and CNO at Advocate Health, about how CNOs can help prevent workplace violence. Tune in to hear her insights.
The health system aims to bring patients, families, and the care team together through smart room technology, says this CNE.
As many health systems employ AI technology and virtual nursing, the idea of a "smart room" has come to the forefront.
Smart rooms have stationary, built-in technology that can help improve nurse workflows and keep the patients safe and comfortable. Some of the technologies include ambient listening, virtual nursing setups, and smart beds and wearables that can help measure a patient's vital signs.
OhioHealth launched the new Pickerington Methodist Hospital in December 2023, which according to Cynthia Latney, senior vice president and CNE at OhioHealth, and HealthLeaders Exchange member, is an 86-bed hospital that will create a different experience for patients and their families.
According to Latney, the patients at OhioHealth are looking for value, safety, and connection with their caregivers, which are all aspects that can be addressed with technology.
"Coming out of the pandemic, we saw the benefits of using technology to help support our caregivers," Latney said, "and we saw the benefits of keeping our patients safe."
Technology
Latney was excited to bring the new technology, which is called the virtual care model, to OhioHealth, with the aim of bringing patients and families together.
The virtual care model, according to Latney, includes a large screen at the front of the patient's room and a camera. The patient can interact with the TV and use a tablet to find out who is on their care team, ask for the pharmacist or the meal trays, or to make general requests from the care team. Virtual nurses are also able to use the technology as part of their workflows.
The room technology also enables families to enter the hospital room without having to physically come to the hospital.
"If you're talking about somebody who's had a new baby and you have a large family, [and] you want to give the mom and dad some privacy, but they want to see the new baby," Latney said. "We're using the technology so the whole family can come meet the baby virtually and give the privacy to the mom and dad."
Integration with nurse workflows
The virtual care model has three aspects. The first is a primary nurse that sees the patient in person and is responsible for care. Then there is a patient care aid and the provider, and a virtual nurse who bridges any gaps.
"[The virtual nurse] sits in between the technology and looking at the medical record, and the care team that is seeing the patient directly," Latney said.
Many of the tasks that the virtual nurse does are what the primary care nurse can give to them, including shift reports, admissions and discharges, care coordination, and reviewing the record to make sure there is no missing documentation.
The virtual nurse also helps develop patient care plans and support new nurses.
"When you have a new nurse that comes into the room and they need support, then you have the [virtual nurse] that pops in that can be there in the background to help support them," Latney said, "or they can be the second eyes for a nurse who needs a double check."
A virtual nurse remains in place 24/7 to help no matter what, Latney said.
"Today when our nurses are thinking about leaving, it is about their environment and all the things they have to do," Latney said.
The virtual nurse helps reduce the bedside nurse's anxiety and their workload so that they can spend more time with the patient.
"As nurses, we want to be there for our patients and our families, and not spending a lot of time on the phone or in the medical record," Latney said, "but really be able to function and practice at the top of [our] license."
Outcomes
The nurse and patient reaction to the new hospital has been positive, according to Latney. The nurses value the technology and are happy to have someone there to help with documentation and pulling information, which is a burden that would typically fall on them.
The patients also appreciate having somebody there that they can call at any point for questions or other information without worry, Latney said.
"They understand the importance of having a primary nurse with them," Latney said, "but when they need to reinforce information or they have a question, they really think about their nurses and who they're pulling away from."
The care model has also benefited nursing students, according to Latney. New graduate nurses now have the support they need from a more experienced nurse at the push of a button.
"Our nursing students come into Pickerington Methodist Hospital, and they [say], 'I just feel so good that I have somebody that's with me,' and they can't wait to graduate and come join the team," Latney said.
In terms of ROI, Latney said service and quality scores have increased or remained positive, and staff satisfaction has been positive. Leadership asked the front lines to design the model collaboratively, so the staff felt valued throughout the process.
"We knew that they needed support," Latney said, "but we wanted to make sure that we designed it based on their feedback and what they valued."
Latney pointed out that the program is still new, and that it will take time to measure all of the possible outcomes of the new hospital.
"It's a new hospital, so we're going to need time to really evaluate the impact of this new model," Latney said. "At the same time, we understand this is a model for the future."
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Workplace violence prevention takes efforts from the health system and the community, according to this nurse leader.
HealthLeaders spoke to Mary Beth Kingston, executive vice president and chief nursing officer at Advocate Health, about how to CNOs can prevent workplace violence. Tune in to hear her insights.
