Healthcare Transformation: Factors, Impact, and Nurse's Role

This report provides a comprehensive overview of healthcare transformation, examining the key factors driving change, such as fragmentation, unsustainable costs, and an aging population. It explores the impact of longer life expectancy and the concept of continuum of care, as well as newer models like accountable care organizations and medical homes. The report emphasizes the crucial role of nurses in leading these transformative changes, particularly in community-based healthcare systems. It includes a summary and analysis of the responses from three nurses, highlighting their perspectives on preventative care, care coordination, and the patient-centered medical home model, demonstrating the importance of nurses in improving quality, outcomes, and reducing healthcare costs. The report references various studies and initiatives to support its findings.

Running head: HEALTHCARE TRANSFORMATION
HEALTHCARE TRANSFORMATION
Name of the student:
Name of the university:
Author note:

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Brochure:
Factor driving healthcare transformation:
 In the present generation, a number of factors have been identified that would be
driving healthcare transformation in the healthcare centres. These factors include the
fragmentation as well as different access problems faced by different people in the
nation (Salmond et al., 2017).
 Other driving factors are the unsustainable costs as well as suboptimal outcomes and
even disparities. Studies are of the opinion that cost and quality concerns along with
the different changing social and disease type demographics had put forward the
urgency for need for change.
 Different initiatives like the affordable care act include different programs which are
led by Centres for Medicare & Medicaid Services (Boswell & Cannon, 2018). These
programs are aiming in the improvement of quality and control cost. Greater
coordination of care is now aimed to be achieved across different providers and
settings that will help in improving a number of aspects of healthcare. This will help
in improving quality care, service outcomes, and reduction in spending mainly in
cases of unnecessary hospitalisation, unnecessary emergency department utilisation,
adverse drug interaction, repeated diagnostic testing and many others (Young et al.,
2017).
 Nurses will be playing an important role in contributing as well as leading the
transformative changes that are taking place in the healthcare. This can be achieved
by nurses by being a contributing member of the inter-professional teams as the shift
is being made from provider based, episodic, fee for service to different types of
patient centred, team-based care across the continuum that would be providing
seamless, affordable and even quality care (Duffy, 2018).

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Impact of longer life expectancy of people:
 The advancement of modern medicine and technological innovations had helped in
increasing the longevity and life expectancy of people. However, they have not been
able maintain the quality of life of people as more and more aging population are seen
to be suffering from different non-communicable disorders numbering from one to
many multi-morbid disorders (Bodenheimer et al., 2016).
 Hence, the increasing number of population requiring healthcare services for their
chronic ailments are depicting the necessity of recruitment of more number of nurses
to sufficiently care for all people irrespective of their culture and backgrounds.
 In order to match up to the needs of the growing aged population, more nurses are
required to maintain a stable and safe nurse patient ratio. Hence more nursing jobs
would be required.
Concept of continuum:

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Community based healthcare systems have proposed the concept of continuum of
care. It is a concept of a system that successfully guides and tracks various patients over a
period of time through a comprehensive array of health services that would be spanning at all
levels and intensity of care (Pittman et al., 2015). This concept is also believed to cover the
delivery of healthcare over a period of time and might also refer to care services and
monitoring starting from time of birth to that of death.
Accountable care organizations:
Accountable care organisations are considered as newer concepts where groups of
healthcare professionals, doctors as well as other healthcare providers are seen to come
together voluntarily for giving coordinated high quality and safe care for their Medicare
patients (Fraher et al., 2015). They have the main aim that people get right kind of services at
the right time without duplication of any forms of services and prevention of medical errors.
Medical home:
This can be described as the model or philosophy of primary care that nurses should
incorporate in their practices. This model of care should be should be patient centred, team-
based, comprehensive, accessible, coordinated and should be focusing on quality and safety.
Healthcare professionals need to meet patients where they are present that might include

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simpler to most complex situations (Hain & Fleck, 2014). It can be considered as a model
aiming to achieve primary care excellence so that right care is given at right time and right
place and in the best manner that suits the needs of patient.
Nurse managed health clinics:
These are community based primary healthcare centres that usually work under the
leadership of advanced practice nurses. They are mainly seen to emphasize on health
educations, disease preventions, healthy promotion and many others for developing the
quality of life of people who are mostly undeserved, face discrimination as well as that of the
ordinary people (Adaji et al., 2018).
Summary and analysis of the response of the three nurses:
Mrs Lisa was of the opinion that the coming years would witness huge demands on
the number of nurses presently working in organisations. The generation is experiencing
longer livelihood of people whose life expectancy had increased because of better medicine
availability and treatment options that prevent death. However, she had rightly identified the
trend that although more and more people are living, their quality of life is not managed
effectively and hence they are seen to admit to hospitals with critical cases of unmanaged
chronic disorders. Huge expenditure of healthcare resources on their treatment takes place
that provide pressure on healthcare funding (Freidberg et al., 2014). Therefore, she was of the
opinion that preventative care treatment plans should be the main motto of present day
nurses. Her opinion was more or less similar to my thinking procedures. More number of
nurses need to be appointed in the primary healthcare centres as these centres are the first

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areas where patients visit for help regarding their health issues. Therefore, in these sessions
only, nurses need to fulfil the role of health educators and develop health literacy among
patients. They need to make them aware of the different risks and lifestyle factors that they
need to manage in order to live healthy lives. I believe this would automatically reduce the
chances of unmanaged chronic ailments and hence reduce hospitalisation rates.
Mr. Samuel was seen to be praising the new role of nurses as care coordinators which
I had not discussed in the presentation. He told me that he had liked the presentation and his
beliefs and ideas about nurse’s role in the new healthcare transformation system are
absolutely perfect and on-track. The community healthcare centres are now allocating
complex care coordinators, chronic care managers, care mangers and similar positions. His
discussion had enlightened within me a new concept that I had not discussed in my
presentation but aligned with the different aspects of healthcare transformation that I
discussed. These people are nurses who are seen to manage patients with chronic conditions
and help them to stay well and lead quality lives as far long as possible. He opined that job
role of such nurses comprise of formulating discharge plans and also ensuring that patients
are following through their appointments and adhere to medication schedules. He convinced
me that as the new system of healthcare am trying to make professionals work in ways by
which they can reduce readmissions and lower the costs under the umbrella of bundled
payments, the role of care coordinators have evolved. In the present generation, I have also
noticed that care coordinators take charge of managing care of patient from surgery to 90
days post acute treatment. Studies have already proved that registered nurse who undertakes
such roles can provide more effective care for a diabetes and high blood pressure patient than
these patients who are managed by physicians alone (Cene et al., 2016). Thereby such nurses
prevent chances of patients getting readmitted due to poor post discharge self-management
and care.

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Miss Susanne was seen to be supporting the concept of medical home as her feedback
revealed that this concept has the ability to provide best quality care to patient and making
them responsible about their own care. These would reduce chances of readmission to
healthcare centres along with preventable health disorders and hence prevent huge flow of
healthcare resources. She supported my opinion regarding the medical home concept. She
suggested that “patient centred” attributes help in developing an effective partnership among
patients, families and professionals. This ensures that ultimate healthcare decision that would
be taken would respect the wants, needs and preferences or patients. This would develop their
accessibility to healthcare services. They would also be educating and supporting patient so
that they can make decisions and participate in their own care. This would increase the
responsibility of patients and make them feel empowered, this would help in making them
adhered to their own treatment and hence readmissions as well as unmanaged health
conditions would be prevented handled effectively (Pittman et al., 2015). Comprehensive,
coordinated and accessible care by nurses along with commitment and safety would help
patients to get cured through community services only and hence healthcare resources can be
saved. Personalised care plans, medication reviews, coaching patient and giving them advice,
supporting and encouraging patients are some of the actions from under medical home
concept. This would help in effective healthcare transformation and protect people

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References:
Adaji, A., Melin, G. J., Campbell, R. L., Lohse, C. M., Westphal, J. J., & Katzelnick, D. J.
(2018). Patient-centered medical home membership is associated with decreased
hospital admissions for emergency department behavioral health patients. Population
health management, 21(3), 172-179.
Bodenheimer, T., & Mason, D. (2016, June). Registered nurses: Partners in transforming
primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr.
Foundation in June.
Boswell, C. & Cannon, S., (2018). Introduction to nursing research: Incorporating evidence-
based practice. Jones & Bartlett Publishers.

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Cené, C. W., Johnson, B. H., Wells, N., Baker, B., Davis, R., & Turchi, R. (2016). A
Narrative Review of Patient and Family Engagement: The “Foundation” of the
Medical Home. Medical care, 54(7), 697.
Duffy, J. R. (2018). Quality Caring in Nursing and Health Professions: Implications for
Clinicians, Educators, and Leaders. Springer Publishing Company.
Fraher, E., Spetz, J., & Naylor, M. D. (2015). Nursing in a transformed health care system:
New roles, new rules.
Friedberg, M. W., Schneider, E. C., Rosenthal, M. B., Volpp, K. G., & Werner, R. M. (2014).
Association between participation in a multipayer medical home intervention and
changes in quality, utilization, and costs of care. Jama, 311(8), 815-825.
Hain, D., & Fleck, L. (2014). Barriers to nurse practitioner practice that impact healthcare
redesign. OJIN: The Online Journal of Issues in Nursing, 19(2).
Pittman, P., Bass, E., Hargraves, J., Herrera, C., & Thompson, P. (2015). The future of
nursing: monitoring the progress of recommended change in hospitals, nurse-led
clinics, and home health and hospice agencies. Journal of Nursing
Administration, 45(2), 93-99.
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for
nursing. Orthopedic nursing, 36(1), 12.
Young, H. M., Bakewell-Sachs, S., & Sarna, L. (2017). Nursing practice, research and
education in the west: the best is yet to come. Nursing research, 66(3), 262-270.