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Editorial: Where Is Rehabilitation Nursing in the Healthcare Reform Debate?
Every year approximately 20% of discharged Medicare patients are readmitted within 30 days and 56% within 1 year (Jencks, Williams, & Coleman, 2009). Although the percentages vary considerably (e.g., 13% in Idaho and 23% in Washington DC), it is apparent that readmissions are frequently associated with inadequate follow-up after discharge and ineffective physician-patient communication, which contributes to poorer health outcomes and increased readmission costs (Epstein, 2009; Jencks et al.). Of particular importance is what happens to the escalating numbers of people with disabilities and chronic illnesses who have healthcare needs of greater duration and require more comprehensive and coordinated interdisciplinary care.
Politicians, special interest groups, and the media have bombarded us with the recurrent theme “the healthcare system is broken.” Admittedly, there are system aspects that need to be changed and the fee-for-service payment system has created incentives that reward high volumes of care rather than high-quality, coordinated, interdisciplinary care. Moreover, some healthcare providers have predominately focused on their roles and priorities without placing a major emphasis on patients’ preferences as well as effective coordinated patient transition from one care setting to another (i.e., emergency rooms, hospital admission, outpatient clinics, doctors’ offices, and long-term care).
Experts within the political, insurance, and healthcare systems are now considering a bundled episodic care-based payment system that rewards well-â€¨coordinated health care, improved patient outcomes, and an increased emphasis on preventative care. However, we remain unclear on how this system will be paid for our work. Where will rehabilitation care fit in this matrix? What role will rehabilitation nursing play? And perhaps most importantly, what do patients want? Will patients be accountable and active participants in setting their healthcare goals with healthcare professionals while developing specific and feasible individualized action plans to achieve positive outcomes?
A central component of rehabilitation is the holistic, comprehensive, interactive approach of an interdisciplinary team that operates in both inpatient and outpatient settings. The active participation of patients and their caregivers is a cornerstone of the rehabilitation process. Our goals are to help facilitate patients’ therapy adherence, optimal community integration, and continued quality of life for patients despite their impairments. Given this long history of documented coordination, effective communication, and improved outcomes, why is rehabilitation not mentioned as a key element in the healthcare debate? Results from Jack and colleague’s (2009) randomized control trial reveal that coordinated packages of nursing and pharmacy services added to the typical care-delivery process helped reduce hospital readmissions within 30 days of discharge. For instance, each year in the United States more than 32 million adults are discharged from hospitals, many of whom have chronic illness requiring long-term care follow-up and interventions (Levit, Ryan, Elixhauser, Stranges, Kassed, & Coffey, 2008). It is imperative that including rehabilitation in the bundle of healthcare services be considered in any healthcare reform discussion. As suggested by the Jack study and others, there is strong evidence that nursing and other healthcare professionals must be involved—not just physicians, healthcare insurance companies, lobbyists, and attorneys.
Although urgency is a predominant theme pertaining to healthcare reform, clinicians recognize that successful outcomes are more likely to occur when prudent data-based decisions are combined with effective communication and cooperation between all stakeholders (i.e., patients, families, healthcare professionals, healthcare institutions, insurance companies). In addition, changes in preventative and rehabilitation-focused behavior requires a blend of creative and culturally appropriate long-term strategies that do not assume one size fits all. Moreover, a central element of healthcare reform must be accountability of all stakeholders in conjunction with the expeditious implementation of the highest level of evidence-based practice in all settings whether it is the hospital, outpatient, home, or long-term care.
At this critical time in healthcare reform, nurses need to remain vigilant regarding new legislation being proposed and must stay active with their professional groups such as ARN and others. Now is not the time to sit on the sidelines. We need advocates for ourselves, our patients, and their families. Given the important contribution of rehabilitation nursing to quality of life and enhanced patient outcomes, we must ensure that rehabilitation is included in healthcare reform.
Epstein, A. M. (2009). Revisiting readmission—Changing the incentives for shared accountability. New England Journal of Medicine, 360, 1457–1459.
Jacks, B. W., Chetty, V. K., Anthony, D., Grennwald, J. L., Sanchez, G. M., Jonson, A. E., et al. (2009). A reengineered hospital discharge program to decrease hospitalization. Annals of Internal Medicine, 150, 178–187.
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalization among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418–1428.
Levit, K., Ryan, K., Elixhauser, A., Stranges, E., Kassed, C., & Coffery, R. (2008). UCUP facts and figures: Statistics on hospital-based care in the United States in 2006. Retrieved September 10, 2009, from www.hcup-us.ahrq.gov/reports/factsandfigures/HAR_2006.pdf retrieved 9-7-2009.