Journal of Community & Public Health Nursing
Open Access

Abstract

Care Coordination is a core element of the Veteran-centered experience and requires an effective, well-educated nursing staff. A greater understanding of roles and tasks being carried out by nurses in primary care was needed to help determine how best to implement care coordination and transform the PACT model. We conducted an observational study of primary care nursing at the Miami VAHS by creating a classification schema for nursing responsibilities, directly observing and tracking nurses work, and categorizing their activities. The vast majority of nursing time was spent on vaccine and medication administration; telephone work; and charting and paperwork, while a minimal amount of their time was spent on activities classified broadly as Care Coordination. Care Coordination work appeared to be subsumed by other daily tasks, many of which could have been accomplished by other, lesser trained members of the healthcare team. Practices looking to implement Care Coordination need a detailed look at workflow, task assignments, and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education or license. Care Coordination represents a distinct responsibility that requires dedicated nursing time, separate from the day to day tasks in a busy practice. It is imperative that we support non-visit-based work to achieve improved clinical outcomes and enhance the efficiency of the health system. How Care Coordination has fit into the role currently being filled by primary care nurses remains an unanswered question. Redesigning the primary care system in America has become a national priority as the USA struggles to solve issues of poor access, high cost, and sub-optimal quality. The Institute of Medicine (IOM) recently highlighted the critical role that nurses will play in this redesign, emphasizing the need for nurses to practice to the full extent of their education and training (IOM, 2011). We have implemented PACT, an enhanced model of primary care delivery that requires extensive practice redesign. This model contains many elements that require an effective, well-educated nursing staff. A greater understanding of the roles and tasks of nursing in this model is needed to help guide practices implementing the PACT. Nurses play a natural role as facilitators in Care Coordination models, particularly in a relational care context or when acting as boundary spanners. Enhanced access to primary care is only one element to consider when addressing the expansion of nursing scope-of-practice. The fragmentation of our health care system demands that resources be applied to improving care coordination as a whole. If done with care, this will result in better healthcare. With this in mind, any further attempt to broaden scopes of practice in the healthcare industry should err on the broader side. Primary care providers, whether physicians, nurses, pharmacists, social workers, or other community services support workers, should be permitted and encouraged to practice to the fullest extent of their licenses, but more importantly, all providers should be trained to engage and support the patient as a key member of his or her own health team.

Biography

E-mail: Leslie.Caesar@va.gov