Clinical Role and Leadership Role

Review the clinical and administrative roles outlined in the following article: Scope and standards of practice for registered nurses in care coordination and transition management. (2015). Retrieved from ProQuest Ebook Central.
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Choose a clinical and administrative role that is of interest to you and discuss how these roles, their associated responsibilities, and functional areas contribute to effective home health care delivery.
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"Clinical Nurse Specialists: Leaders in Managing Patients with Chronic Conditions"
Headnote
The complex care of patients with chronic conditions threatens the stability of healthcare economics. Clinical nurse specialists, in roles that leverage full scope of practice, positively impact the Triple Aim and are vital to meeting this rising need.
We live in an era where over 50% of health care is devoted to attention around chronic conditions (Ward, Schiller, & Goodman, 2014), which account for 7 of the top 10 causes of deaths and contribute to 74% of all deaths in the United States (Murphy, Xu, Kochanek, & Arias, 2018). With the tsunami of older adults expected to reach 98 million by 2060 (U.S. Department of Health and Human Services [HHS], 2016), the provision of care for persons with chronic conditions poses increasing economic burdens. Care of this population accounts for 86% of U.S. healthcare costs (Gerteis et al., 2014) and becomes even more inordinate in individuals with multiple chronic conditions and complex social determinants of care (Craig, Eby, & Whittington, 2011). The National Association of Clinical Nurse Specialists (NACNS) sensed this urgency and appointed a taskforce to demonstrate clinical nurse specialists (CNSs) as leaders in the care of patients with chronic conditions (NACNS Chronic Conditions Task Force, 2017). This article includes information from the work of taskforce members as well as additional evidence that CNSs are uniquely prepared to lead and manage populations of patients with chronic conditions and positively affect health care and nursing economics.
Background Information
CNSs are master or doctorate-prepared advanced practice registered nurses (APRNs) whose function is to improve outcomes in patient care, support the work of the nurse, and lead practice changes across healthcare systems. CNSs are uniquely prepared in evidence-based practice to drive outcomes by moving fluidly across the three spheres of CNS influence known as patient, nurse, and system (NACNS, 2018). The CNS raises the level of care and improves work processes and patient satisfaction while lowering costs of care (Saunders, 2015).
The competencies of CNS practice are direct care, consultation, systems leadership, collaboration, coaching, research, ethical decisionmaking, moral agency, and advocacy (NACNS, 2010). A sample behavior for each competency, listed in Table 1, shows the breadth of CNS practice. For example, in the direct care competency under the nursing sphere, CNSs address the six components of quality care issued by the Institute of Medicine (IOM, 2001). The sample behaviors show the autonomous nature of CNS practice; demonstrate how the role supports accessible, high-quality, evidence-based health care; and depicts reimbursable CNS services (NACNS, 2010).
A CNS practices where leadership is needed and responds to the ever-changing climate in health care (NACNS, 2010). One distinguishing attribute of the CNS is the ongoing incorporation of the science of nursing that is based on current evidence facilitating the recognition of patterns in health behaviors in order to make changes to improve outcomes. It is this expertise in managing patient populations, especially those with chronic conditions, that augments self- management and bridges gaps in the continuity of care (NACNS, 2017).
The literature frequently refers to complex care as that which considers the social determinants of health as integral to the provision of medical care (NACNS, 2017). There is increasing evidence that social factors have greater impact on health outcomes than do medical services (McGinnis, Crawford, & Somers, 2014). These challenges present opportunities for improving care coordination. While this strategy is largely recognized as key to reigning in healthcare costs, models such as Accountable Care Organizations have not achieved this outcome in patients with multiple chronic conditions and multiple providers (McWilliams, 2016). The CNS, under state licensure, national core competencies, and scope of practice developed within the Consensus Model for APRN Regulation (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008) is well positioned to promote and enhance evidencebased practice within the complexities of health care for this patient population.
CNS as Independent Practitioner
The CNS has emerged as an expert nurse and independent practitioner. This emergence may be due in part to the impact of the Affordable Care Act (ACA). Although the ACA increased insurance coverage to citizens who had been uninsured, this did not translate into equitable access for all. Increased volumes of persons with multiple chronic comorbidities coupled with a lack of a sufficient number of providers has created a healthcare system driven by penalties for increased length of stay and avoidable hospitalizations (Gaffney & McCormick, 2017). To assist in the management of this population, many states have endorsed CNSs to provide care as independent practitioners with prescriptive authority (Brush et al., 2015; NACNS, 2016; National Council of State Boards of Nursing, 2015; Ray & Mittelstadt, 2016). This expansion in scope of practice has created an opportunity for CNSs to fill a growing deficit of primary care providers (PCPs) in ambulatory care settings (Johnson & Garvin, 2017).
Governing bodies as well as legislative movements at the federal, state, and local levels endorse the CNS as an APRN and independent practitioner (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008). The IOM recommends healthcare systems and regulatory bodies break down barriers that hinder nurses from practicing to the full extent of licensure (IOM, 2011). CNSs support policy that enables them to practice as independent providers with prescriptive authority and desire a greater role in prescribing to facilitate care in patients with chronic conditions (Saunders, 2015). When CNSs practice with prescriptive authority, access to care is streamlined (Klein, 2015) and provides a significant intervention for vulnerable populations. As CNSs treat patients in critical access sites, their referrals, to and within the larger system, align with the organizational strategic plans and generate income while utilizing a business case approach to care (Ellis, Embree, & Ellis 2015).
CNS practice across all healthcare settings has demonstrated positive quality outcomes including a decrease in complications, reduced readmissions, lower costs of care in patients with chronic conditions (Bryant-Lukosius et al., 2015; Negley, Cordes, Evenson, & Schad, 2016; Ulch & Schmidt, 2013) and improved nurse/staff satisfaction (DeJong & Veltman, 2004; Saunders, 2015). Table 2 provides evidence from the literature supporting the productivity of the CNS when full scope of practice is employed across the continuum of care.
CNS Impact on the Triple Aim
The Triple Aim represents the simultaneous pursuit of improving population health, enhancing patient satisfaction, and reducing healthcare costs (Berwick, Nolan, & Whittington, 2008). The Centers for Medicare & Medicaid Services (CMS) created new challenges for systems when it began to shift from a volume to a value-based purchasing (VBP) model. This swing from volume to VBP focused on quality metrics with specific requirements for decreased emergency department utilization and hospital readmissions (Tompkins, Higgins, & Ritter, 2009). By 2018, the HHS planned to transition 90% of Medicare reimbursement to VBP (CMS, 2016). The demands of achieving the outcomes of the Triple Aim associated with a rapidly changing healthcare environment create increased stress for healthcare providers (HCPs) that fuel burnout and undermine its achievement.
Attention has recently been drawn toward a Quadruple Aim focus which embraces the three legs of the Triple Aim (cost, quality, and satisfaction) and also addresses the work life of the HCP. An unfavorable work life leads to burnout and threatens the Triple Aim. Allowing full scope of practice to every HCP reduces burnout and improves care (Bodenheimer & Sinsky, 2014). Systems that accommodate a structure allowing the CNS to influence nurse, patient, and system spheres of care are positioned more readily to achieve, not only the Triple Aim, but the Quadruple Aim. Ongoing healthcare reform continues to highlight the added value a CNS brings to the treatment team (NACNS, 2013). HHS recognized a cost savings of $330 million per year for hospitals that aligned privileges of non-physician providers, which includes APRNs, with state laws and scope of practice acts (HHS, 2012). Evidence within the literature supports the positive impact of CNSs on the Triple Aim.
CNS Reimbursable Care
The ability of providers to contribute to the revenue stream is an important construct of healthcare economics. CNSs are among providers approved for billing through CMS. Table 1 highlights reimbursable CNS behaviors. Medicare accepts billing for CNSs who are licensed by the state, have a master or doctorate-level degree in nursing, are certified by a nationally recognized credentialing body, and employed at a facility that accepts Medicare payments. CMS introduced codes for Chronic Care Management and Complex Chronic Care, recognizing the systematic assessment, comprehensive care planning, and complex care coordination required for patients with chronic conditions. CNSs are designated providers allowed to use these codes (CMS, 2017). Efforts on the part of administrators and CNSs to understand details of billing related to chronic conditions are imperative to maximizing opportunities that generate revenue. Direct care provided by a CNS is reimbursable by agencies such as CMS at 85% of the physician rate. This is a substantial generation of revenue and cost savings in markets where lack of PCPs has led to overutilization of services in the acute care setting (Fraser & Melillo, 2018).
Emerging Solutions
Technology
The American Recovery and Reinvestment Act of 2009 offered financial incentives to healthcare providers and spurred use of electronic health records by all health organizations (CMS, 2009). This explosion of healthcare information has led to a number of virtual programs and ease of access to health information by consumers. Integration of technology includes tools used as interventions such as telehealth and telephone applications used by consumers and providers to manage chronic conditions. Telehealth is reimbursable by CMS for chronic conditions when meeting defined criteria (CMS, 2018).
With the availability of patient portals and mechanisms of delivering health information, there are challenges to its usability. These advancements have led to the concept of population health informatics which entails identifying utilization of data to improve the health of specific populations (Kharrazi et al., 2017). The CNS evaluates the use of technology to serve patient/families for self-management of conditions, nurses in practice for improved patient care, and systems for the ideal retrieval of documented information to determine best care (NACNS, 2010).
Transitional Care
CNSs are successful in developing partnerships from within the acute care setting to facilitate transition of the patient and consistency in the longitudinal plan of care to the ambulatory care setting (Negley et al., 2016). CNSs practicing to the full extent of licensure in the management of patients with chronic conditions mitigate the barriers that exist between hospital and post-acute care efforts. Effective transitional care practices streamline the resources utilized throughout the continuum of the lifespan.
Conclusion
The dynamics of the rapidly growing population of individuals with chronic conditions challenge the financial integrity of healthcare systems. This population is often fraught by social determinants of health which present complex care needs and require high-level care coordination. CNSs by state licensure, national core competencies, and scope of practice have the aptitude and skill to manage these needs and address existing healthcare system gaps.
Evidence supports the practice of CNSs and their impact on the Triple Aim, the gold standard of quality care. CNSs improve access to care, drive care coordination, provide staff mentorship through expert-level nursing, and impact the economics of health care through reimbursement and cost avoidance. Advancements in care delivery strategies, such as technology-driven solutions and transitional care, present system opportunities and challenges that CNSs address through their spheres of influence. CNSs provide outcomes-based solutions for healthcare systems in the management of patients with chronic conditions.