53/1 Dis

Journal of Professional Nursing 33 (2017) 400–404

Contents lists available at ScienceDirect

Journal of Professional Nursing

Original Articles

Is health care payment reform impacting nurses' work settings, roles, and education preparation?

Mary Val Palumbo a,⁎, Betty Rambur b, Vicki Hart c a University of Vermont, College of Nursing and Health Sciences, 106 Carrigan Drive, Rowell 216, Burlington, VT 05405, United States b University of Rhode Island, Routhier Endowed Chair for Practice, College of Nursing, 39 Butterfield Road, Kingston, RI, 02881, United States c University of Vermont, Office of Health Promotion Research, 1 South Prospect Street, Rm 4428, Burlington, VT 05401, United States

⁎ Corresponding author. E-mail addresses: [email protected] (M.V. Palumb

(B. Rambur), [email protected] (V. Hart).

http://dx.doi.org/10.1016/j.profnurs.2016.11.005 8755-7223/© 2016 Elsevier Inc. All rights reserved.

a b s t r a c t

a r t i c l e i n f o

Article history: Received 11 August 2016 Accepted 28 November 2016

This study explores nurses' work settings and educational preparation in the five years before passage of the Af- fordable Care Act (ACA) and five years after ACA passage, with the aim of identifying areas for nurse educators' attention. The study setting was one small state undergoing rapid transition away from fee-for-service service and thus provided the ideal laboratory to assess the impact of health reform on the nursing workforce. A second- ary analysis of data gathered during relicensure compared the nursing workforce at an interval of one decade, with surveys in 2005 (n = 4075; 65% response rate) and in 2015 (n = 6723; 97% response rate). Findings dem- onstrated an increase in the proportion of nurses who reported working in ambulatory care and community set- tings (p = 0.001). However, there was no associated decrease in the proportion of nurses who reported working in hospitals. Among respondents who reported employment in the ambulatory care/community settings in 2005, 34.3% had a BSN or higher, a proportion that increased to 41.2% in 2015 (p = 0.010); nevertheless, the greatest proportional increase was among AD prepared nurses (34% to 48%). Although new nursing roles emerging as a result of health reform offer baccalaureate nurses the opportunity use the full complement of their knowledge and skills, these data suggest that BS prepared nurses are not fully accessing these opportunities. Implications for nursing education and further research are detailed.

© 2016 Elsevier Inc. All rights reserved.

Keywords: Ambulatory care Nursing education Payment reform

Introduction

Health care reform and the growing momentum in the volume-to- value transition creates a new environment for nursing practice. Health reform rooted in “The Triple Aim” of 1) improved patient experiences, 2) improved population health, and 3) cost containment has seeded the development of new payment models and redesigned care delivery. Responsibility for population health and overall cost of care broadens the accountability horizon for organizations. Instead of responsibility for an episodic encounter that is billed and reimbursed, payment reform creates incentives to understand the value of care, the longer term im- pact of clinical decision making on cost of care and patient overall health and well-being, and population-level costs. Thus, payment reform is an element of health reform that potentially creates particular opportuni- ties for new or renewed roles for nurses. In traditional fee-for-service re- imbursement schemas, for example, many nursing skills (such as care management and patient education) equate to a “labor cost,” while medical services are perceived as a “revenue generator.” Payment re- form dramatically shifts this equation, suggesting the potential for

o), [email protected]

more nursing employment in non-acute care settings. Yet have nurses' work settings and roles evolved as well? This preliminary study ex- plores nurses' work settings in the time of reform, five years pre-Afford- able Care Act passage and five years post ACA passage, with the aim of clarifying potentially fruitful areas for curricular reform and empirical- ly-based nurse continuing education.

Background and Context

One element of health reform, the Affordable Care Act of 2010 (ACA), creates a path toward universal health insurance that builds on the existing U.S. hybrid financing model of governmental payers (Medicare, Medicaid, Children's Health Insurance Program, or CHIPS, and TriCare) and commercial insurance. It requires that all individuals are covered by one of these means, either via one of the governmental insurances or commercial insurance. Commercial insurance may be employer- based or individually purchased. The law also requires each state to ei- ther create a “Health Insurance Exchange” or to participate in the federal exchange. The purpose of the exchanges are to enable individuals and small businesses to compare different health insurance plans in an “ap- ples to apples” manner because all plans must include the “essential benefit package”, i.e., services that much be covered. What differs among the plans is the “actuarial value” of the plans, the amount of

Table 1 Key provisions of U.S. Department of Health and Human Services January 26, 2015 announcement

Timeline of Medicare Value Based Initiative Date

30% of traditional fee-for-service to value based payments By end of 2016 50% of traditional fee-for-service to value based payments By end of 2018 85% of all tradition medicare payment to quality or value By end of 2016 90% of all traditional medicare payment linked to quality or value By end of 2018

401M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

cost sharing in the form of copayment, deductible, and coinsurance. These are also standardized by what is termed metal levels. For exam- ple, in a plan with a 60% actuarial value (AV)—a bronze plan—the in- sured would pay roughly 40% of health costs but have a lower monthly premium than, for example, a platinum plan, which has an ac- tuarial value of roughly 90%. The law subsidizes those who meet eligibil- ity requirements, provided they select a silver plan (AV value of 70%)

In addition to providing such onramps to health insurance, the ACA creates incentives for testing alternative payment models (APMs) to ad- dress the limitations created by traditional fee-for-service (FFS) reim- bursement, a payment model that fragments care by creating payment silos rather than seamless care across the care continuum. Fee-for-service also fuels accelerating health care cost, overtreatment and overutilization while simultaneously leaving others underserved and undertreated. For ease of understanding, APMs can be bracketed in two broad categories that create differing provider incentives for care and thus different delivery models. The first category is a variant of FFS in which providers are held accountable for the outcomes of care. In the second category, providers bear responsibility for not only the outcomes care but also the cost of that care. Examples of the former include patient centered medical homes, person centered health neigh- borhoods, and other pay-for-performance models in which providers receive additional compensation if quality targets are met. Examples of the latter include most Accountable Care Organizations (ACOs),1 bun- dled payments, and fixed revenue total cost of care “global budgets”. Ac- countability for the cost of clinical decision making, termed “risk bearing,” is new to many providers. In such models, for example, a diag- nosis, prescription, education and follow-up to treat a new diabetic is not adequate. Instead, with payment reform there is a financial incen- tive to assure that the person is managing their diabetes, avoiding hos- pitalization and emergency room visits, and receiving the most effective, least expensive care possible. Conversely, fee-for-service tends to incentivize the most expensive care if the person is well-in- sured. Thus, payment reform away from fee-for-service creates enor- mous opportunities for the management of chronic conditions in a manner that is well aligned with nursing expertise. Medicare's historic 2015 announcement (see Table 1 for details) has greatly accelerated the movement from a fee-for service, volume based system to a value based system; substantial transition was planned for 2016, with a target of 90% of provider reimbursement linked to quality or outcomes by the end of 2018. Moreover, while participation in ACOs is voluntary, Medi- care is requiring bundled payments (one payment for the full episode of care across the care continuum) for joint replacement in over 600 hos- pitals within randomly selected health services areas. In August 2016, two cardiac bundled payments in 98 randomly selected metropolitan areas were added, and the initial orthopedic bundle settings expanded to include lower-extreamity joint replacement. Thus, although the pace at which the payers and providers in various states adopt such al- ternative payment models differs, Medicare's adoption is precedent set- ting. Notably, in traditional FFS, poor quality care receives the same

1 There are three iterations of ACOs, Pioneer, Shared Savings, and Next Generation. Both Pioneer and Next Generation incorporate provider risk bearing. There are four version of Next Generation ACOs, one of which maximizes provider risk-sharing in a fixed revenue model, meaning more services do not equate to more revenue and thereby is the largest contrast to traditional fee-for-service. Shared Savings ACOs have a risk sharing model in which providers assume the cost of care beyond what was projected for a given popula- tion. This is termed “down side risk,” nevertheless, there are “upside only” ACOs in which providers share in any savings above what was projected for the cost of care for a popula- tion provided designated quality metrics are met, but none of the cost. The reader is ad- vised to carefully explore the exact APMs that have been developed and are being developed and tested in their area, as there is dramatic variability throughout the states and even within states. The largest provider groups in the study setting have embraced the Next Generation fixed revenue model and therefore provide a dynamic policy labora- tory. Since the initial draft of this manuscript the study setting has negotiated an agree- ment with Medicare that creates the opportunity for an All-Payer statewide ACO (see http://healthaffairs.org/blog/2016/11/22/the-all-payer-accountable-care-organization- model-an-opportunity-for-vermont-and-an-exemplar-for-the-nation/).

compensation or even better compensation than high quality care. Medicare had begun to address such perverse incentives with reim- bursement policies that preclude reimbursement for same cause read- mission if it is within one month after discharge and fining hospitals whose readmission rate is too high, to name just two examples. Similar- ly, hospital acquired conditions, including those reflecting nurse sensi- tive indicators such as urinary tract infections, no longer generate additional reimbursement. These payment changes have created deliv- ery changes that nurses see regularly in practice. The shift to virtually all reimbursement being tied to value has the potential to completely rede- sign the U.S. health care system. Notably, these changes are exterior to the ACA and rooted in Medicare rules.

The impact of Medicare payment reform cannot be overstated for two primary reasons: 1) Medicare is the payer of health care for a large proportion of Americans, a scenario that is growing steadily with the aging of the Baby Boomer cohort; and 2) Medicaid and commercial insurance often follow Medicare practices, potentially meaning that the value-based scenario could represent nearly all of health care reim- bursement, and reimbursement shapes practice behavior.

Yet what about nursing roles in a reformed system? Workforce re- searchers Fraher, Ricketts, Lefebvre, and Newton (2013) underscore the pivotal role of registered nurses, as follows:

Because of sheer numbers—the U.S. health care system employs 2.7 million registered nurses—it is nurses who are arguably in the most piv- otal position to drive system change. … More attention needs to be given, first, to identifying the competencies nurses need in these new roles and, then, to providing continuing professional development op- portunities for nurses who wish to undertake the new functions (p. 1813).

Educational essentials of baccalaureate and higher degree programs (AACN, 2006, 2008, 2011) include skills such as care coordination that are foundational to the emerging payment reform models described above. Nevertheless, there is scant empirical evidence exploring nurses' work setting migrations over time. It is also unclear if health care reform is associated with a change in the composite educational preparation of nurses outside the acute care setting. This is particularly key in the era in payment reform, given that associate degree prepared nurses—the larg- est proportion of the nursing workforce in most regions—typically do not have course work to prepare them to work in population-focused settings or in settings outside of traditional acute or long term care. Thus, this study seeks to clarify if the role and setting shifts portended by health and payment reform are actually emerging.

Specifically, the current study seeks to explore changes in the nurs- ing workforce practice settings by education preparation and other de- mographic factors. One small state undergoing rapid transition away from fee-for service, Vermont, provides the ideal laboratory to assess the impact of health reform on nurses' practice setting and was there- fore chosen as the study setting. 124 (57%) primary care practices in the state are “Blueprint Practices.” the state's term for an intergrated ap- proach to patient centered medical homes (Department of Vermont Health Access, 2014; University of Vermont AHEC, 2013). The state has also passed landmark legislation in 2011 that includes aggressive movement away from tradition fee-for service. Roughly half the state's health services areas were deemed prepared for full risk sharing as the state prepared for an “all payer” model inclusive of a Medicare waiver to enable all-inclusive, capitated, reimbursement rather than fee-for-

Table 2 Elements of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) and Ac- companying Merit Incentive Program (MIPS)

Physician/nurse practitioner fee schedules in fee-for-service—0.5% increase until 2020, then 0%

Reimbursement based on “merit,” determined by metrics inclusive of quality, resource use, clinical practice improvement activities and meaningful use of certified electronic health record technology.

Merit score results in range of reimbursement from −4% to +4% in 2019; −5 to +5 in 2020; −7 to +7 in 2021; and −9 to +9 from 2022 onward. Providers in qualifying alternative payment models are exempt from MIPs and receive 5% incentive payment from 2019 through 2024

Source: Centers for Medicare and Medicaid Services (2015). Retrieved from https:// www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value- Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html on August 5, 2016.

Table 3 Demographics.

Demographics 2005 all n = 4075

2005 a/c n = 319

2015 all n = 6723

2015 a/c n = 668

Gender 94% female 99% female 91% female 94% female Mean age 48 years 49 years 48 years 49 years Caucasian 95% 96% 93% 628 (94%) Other races 2.8% 0.3% 3.5% 19 (3%) Hispanic (1%) (0%) (4%) 8 (1%) Missing race data 2.2% 4% 4% 25 (4%)

Position/major activity 2005 all n = 4075

2005 a/c n = 319

2015 all n = 6723

2015 a/c n = 668

Patient care 2554(63%) 227 (71%) 4697 (70%) 485 (73%) Consultant n/a n/a 126 (2%) 12 (2%) Nurse executive 168 (4%) 6 (2%) 194 (3%) 15 (2%) Nurse faculty/teaching 217 (5%) 15 (5%) 195 (3%) 6 (1%) Nurse manager 354 (9%) 29 (9%) 738 (11%) 80 (12%) Other 762(19%) 41 (18%) 754 (11%) 69 (10%)

Education 2005 all n = 4075

2005 a/c n = 319

2015 all n = 6723

2015 a/c n = 665

Diploma 849 (21%) 92 (29%) 621 (9%) 73 (11%) ADN 1576 (39%) 109 (34%) 3159 (47%) 315 (48%) BSN 1321 (32%) 101 (32%) 2505 (37%) 235 (35%)

402 M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

service. National adoption of such APMs is further catalyzed by the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) and accompa- nying Merit Incentive Program (MIPs-see Table 2 for details on MACRA and MIPs). This legislation provides a 5% financial incentive for pro- viders in APMs and excludes them from MIPs, the latter being a complex set of infrastructure requirements that may still lead to an up to 9% on- going decrease in revenue by 2022. This Federal initiative, notably subtitled “Path Toward Value” and outside the ACA, will further the fi- nancial incentives for reorganization of the US health care system to- ward value and away from the costly, ineffective care that mars the US system. Notably, providers—including nurses—have been socialized in this environment and thus considerable retooling may be required for contemporary practice. Therefore, regardless of current payment re- form in a particular state, the experience of Vermont may hold impor- tant lessons.; practice patterns in the rapidly changing landscape in Vermont may offer other states a predictive snapshot of nursing work- force changes in an era of payment reform.

Hypotheses

The hypotheses guiding this study are as follows: When comparing nursing workforce survey data pre reform (2005)

and post reform (2015) there will be:

1. an increase in the proportion of nurses who report working in ambu- latory care/community settings/Accountable Care Organizations/pa- tient centered medical homes

2. a decrease in the proportion of nurses who report working in hospitals.

3. a decrease in the proportion of associate degree and diploma educat- ed nurses who report employment in ambulatory care/community settings.

4. an increase in the proportion of nurses educated at the baccalaureate or higher degree level who report employment in ambulatory care/ community settings.

MSN 187 (5%) 3 (1%) 382 (6%) 39 (6%) Doctorate 6(b1%) 3 (1%) 30 (0.4%) 4 (0.6%) Missing 131 (3%) 12 (4%)

Aggregate of BS or higher 2005 all n = 4075

2005 a/c n = 319

2015 all n = 6723

2015 a/c n = 665

BS or higher in nursing (37%) (33%) (44%) (42%) BS - other 547 (13%) 20 (6%) 824 (12%) 86 (13%) MS - other 214 (5%) 38 (12%) 360 (5%) 31 (5%) Doctorate (nursing or non-nsg)

6 (0.15%) 0 (0%) (17) 0.25% (DNP)

1 (0.1%)

18 (0.44%) (13) 0.19% (PhD)

Currently enrolled in a nursing program

233 (6%) 15 (5%) 596 (9%) 38 (6%)

Legend: all = all respondents; a/c refers to respondents who reported ambulatory or com- munity settings.

Methods

This is a comparative study using secondary analysis design to ex- amine the nursing workforce at an interval of one decade, 2005 (n = 4075; 65% response rate) and 2015 (n = 6723; 97% response rate). These data are gathered at the time of Registered Nurse licensure re- newal and reflect the Nursing Workforce Minimum Data Set (Cleary & Rice, 2005). There was a slight difference in the data collection strategy over the course of the decade, based on changes in the state's re-licen- sure protocol. The survey was a voluntary paper survey in 2005, and was legislatively mandated for inclusion in the 2015 relicensure pro- cess. In 2015, the default data collection mechanism was electronic, with a paper survey available upon request. Data were reviewed to

identify nurses who reported practicing in sites listed under the catego- ry of ambulatory care and community health.

Statistical analysis: Descriptive statistics were used to characterize the study population. Chi-square tests of comparison were performed to evaluate the study hypotheses. Results were considered significant at a 95% level of confidence (p ≤ 0.05).

Findings

Hypothesis 1 was supported

There was an increase in the proportion of nurses who report work- ing in ambulatory care/community settings/Accountable Care Organiza- tions/patient centered medical homes. In 2005, 8.0% of respondents worked in Ambulatory Care/Community Health settings. This compares to 10.0% in 2015 (Table 3). This represents a significant increase from 2005 to 2015 (χ2 = 11.5, p b 0.01).

Hypothesis 2 was not supported

There was no decrease in the proportion of nurses who report work- ing in hospitals. Instead, there was a slight increase, which bordered on statistical significance. In 2005, 50.0% of respondents worked in a hospi- tal setting. This compares to 51.9% in 2015 (Table 3). This represents a borderline significant increase from 2005 to 2015 (χ2 = 4.7, p = 0.05).

403M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

Hypothesis 3 was not fully supported

There was a decrease in diploma educated nurses from 2005 (29%) to 2015 (11%) (χ2 = 50.7, p b 0.01); but there was a substantial increase in the proportion of AD prepared nurses, from 34% to 48% (χ2 = 11.7, p b 0.01) (Table 3).

Hypothesis 4 was supported

Among respondents who reported employment in the Ambulatory Care/Community Health setting in 2005, 34.3% had a BSN or higher. This compares to 41.2% in 2015). This represents a significant increase from 2005 to 2015 (χ2 = 9.3, p = 0.01)

Subject demographics and reported position are described in Table 3. Additional post hoc analysis of the 2005 and 2015 data revealed the positions for nurses who reported working in the ambulatory/commu- nity settings (see Table 4).

Discussion

These data suggest that a shift to ambulatory and community based settings is indeed occurring for nurses at all levels of education except the diploma-prepared (who are aging out of the workforce); however, a shift away from hospital employment was not identified. The settings in which nurses are employed is important for many reasons. The N- CLEX exam, for example, serves as the gateway to nursing practice and tests for competency in common practice settings. Historically, the N-CLEX exam has been primarily acute-care oriented and reflected the competencies perceived to be needed for new graduates. Very dif- ferent skill sets are needed in a reformed health system; for example, the use of predictive analytics for individual and population health man- agement. Yet, will competency in these areas be considered a “safe prac- tice” issue and then accordingly be manifest in N-CLEX assessment of essential competencies? The rapid change in payment models portends an equally rapid shift in what constitutes safe and effective practice; therefore, immediate attention to the gatekeeping exam is warranted. Arguably, this will also subtly further shape nursing education. Al- though curricula are explicitly referenced to guidelines such as AACN's Essentials of Baccalaureate Education, in the authors' experience with nurse educators around the nation, the N-CLEX pass rate was an impor- tant implicit factor in curricular emphasis and also one by which pro- grams compare themselves to others, particularly in states where the associate degree pass rate is higher than the baccalaureate. No empirical evidence could be found to support or refute this statement and it re- mains an important, unanswered research question.

The increase in nurses who have obtained the bachelor's degree in nursing or higher in the ambulatory care setting is encouraging, as is the more than doubling of in the actual number of ambulatory care nurses who are currently enrolled in an educational program (15 in 2005 and 38 in 2015). Nurses may be recognizing that the skills needed for population health and transitional care are available through con- tinuing their nursing education. Nevertheless, the overall proportion of nurses who are continuing their education is dismally low, a particu- lar concern given the large proportion of AD nurses working in this set- ting. A larger concern is the substantial increase in the proportion of associate degree nurses employed in ambulatory care. Traditional

Table 4 Workplace settings.

Setting 2005 n (%) 2015 n (%)

Ambulatory/community health 318 (8.0%) 667 (10.0%) Hospital 1986 (50.0%) 3482 (51.9%) Other 1677 (42.0%) 2556 (38.0% Missing 1 (b0.1%) 19 (0.1%) Total 3982 (100%) 6724 (100%)

associate degree education has been acute and long term care centric, with less focus on community and population health. Nevertheless, these data suggest that employers are disproportionately employing these individuals, suggesting that either baccalaureate prepared nurses have not yet been seen as value-added or they are not available for these positons. Additionally, Bevill, Cleary, Lacey, and Nooney (2007) sug- gested that as more nurses achieve a bachelor's degree, there is a better chance that they will further continue their education and be ready to fill needed roles as nurse educators or nurse practitioners. At the same time, it is unclear if baccalaureate prepared nurses are optimizing their potential to utilize a full array of skills and knowledge to support highly functioning emerging models of care.

This study did not find a decrease in the proportion of nurses employed in hospitals. There are a number of potential explanations for this. The ACA has spurred mergers of organizations and a move to- ward integration. The use of secondary data in this study did not enable more nuanced analyses of work role and setting. It is possible that nurses perceive their setting as “hospital” even if they are involved in “same day” options or part of a hospital based Accountable Care Organi- zation, the most common APM in the study setting. Similarly, a transi- tional care nurse working in a congestive health failure demonstration project in the state whose nominal employer is a hospital may not per- ceive themselves as involved in an APM but instead “hospital employed.” Another possibility is that there is no nursing employment shift away from hospital settings, or that the value based movement is just too early in its trajectory to manifest such shifts. Yet another consid- eration is that the ACA enabled previously unensured individuals to ac- cess the system, and there was pent up demand for acute care services among these individuals. Finally, the use of the Minimum Data Set, while offering important consistency and potential for comparisons, is not highly nuanced and may not be sufficiently sensitive. Further stud- ies exploring work roles in detail would be an important complement to this preliminary study

Additional questions are raised by the study: does payment reform create new roles for nurses or just renewed roles? The California Institute for Nursing and Health Care (2013) has detailed nursing roles that have emerged as a result of health reform. These include care coor- dinators inclusive of population health management and tiered coordi- nation, “nurse/family cooperative facilitator” and “primary care partner”. These roles have been further explicated in the 2016 Macy Foundation Conference Recommendations, Registered Nurses: Partners in Transforming Primary Care. As previously noted, traditional workforce data, including the standard Minimum Data Set, may not be sufficiently nuanced to capture and thus reflect such roles and, paradoxically, fur- ther cloud workforce analyses. This may be particularly pronounced when the nurse works across the care continuum in a post fee-for-ser- vice delivery model such as those grounded in bundled payments or global budgets. Nevertheless, these role have the potential to offer sig- nificant value to society and support The Triple Aim. Indeed, as early as 2001, 15 years of evidence defined the attributes of the nurse case manager (Reimanis, Cohen, & Redman, 2001). Attention has also been given to the need for nurses to be prepare to transition from caregiver to case manager (Schmitt, 2005). For nurses to play a leadership role in the evolution of the health care system, enhanced experience in man- aging patient populations is necessary, as these roles will likely become more prevalent. The prerequisite skill set includes the ability to facilitate interprofessional care teams and track patient populations to imple- ment evidence based interventions, then track outcomes as well as the cost.

Nursing faculty control nursing education. Clear delineation of the differences between public health and population health are needed, as well as explication of overlapping skill sets. Reconsideration of curric- ular design is also warranted, as the packaging of courses signals to stu- dents what faculty perceive as important and socializes them within that model. Courses that reflect hospital units (i.e. “Med/Surg”), regard- less of the actual title of the course, are outmoded and inadequate for

404 M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

the changes heralded by payment reform. Similarly, lifespan courses, such “nursing care of children” need contemporary conceptualizations that reflect trends such as “housing as health care” (Doran, Misa, & Shah, 2013) and the use of resources to prevent hospitalization. An ex- ample of the latter would be navigating the social and reimbursement landscape to provide an air conditioner to a poor family whose child has had frequent emergency department visits secondary to particulate induced asthma. These sort of nursing interventions are incentivized in any system in which providers bear risk for the cost of care. Moreover, nurses' holistic orientation that moves well beyond the limitations of the medical model is well suited to these opportunities and responsibil- ities. Clarity on skills expected at the associate degree level and bacca- laureate level as well as role definition is essential. The nurses of this nation will not be prepared for the role shifts accompanying payment reform if both such program types continue to be disproportionally fo- cused on acute care skills, or acute care with the one semester of “com- munity” or public health.

Recommendations for Further Research

Clarity on nurses' work role, as well as employer's perceptions of gaps in workforce skills in the array of payment models would offer im- portant information to nursing education and regulation, including N- CLEX development. Jones-Bell et al. (2014) for example, note that health outcomes for primary, ambulatory, and community health care prac- tices utilizing registered nurses practicing to the fullest extent of their education in the role of care coordinators is important to support cost effectiveness in these critical settings. Yet, care coordination is only one aspect of essential nursing knowledge. Expertise in care redesign to maximize outcomes while reducing cost are prized skills in a nation that currently spends more on health care than any other country, yet has outcomes that consistently lag behind other nations (Squires, 2011).

Team based care is currently a predominate focus in both nursing education and continuing education, yet team based care is a strategy toward the Triple Aim, not an outcome in and of itself. It is currently un- clear how the work role of a nurse in a particular setting intersects with other team members. Also unclear is if the role of “nurse manager” in outpatient settings includes care management that includes other team members or is limited to managing nursing staff in a particular set- ting. Further workforce research is needed to uncover the changes in the work of the nurse manager in the ambulatory care setting.

Value-based payment that is not rooted in fee-for-service educes the use of teams working to the full extent of their knowledge and license because revenue is not driven by physician care or hospitalization. In- deed, in full risk bearing models, all services are a cost. Therefore, essen- tial nursing knowledge in ambulatory care settings will include understanding payment models and the metrics on which organiza- tions are measured as a basis for payment.

Limitations

This study's setting was one U.S. state, which limits nationwide gen- eralizability. Nevertheless, the implications may transfer to other U.S. states in a rapid volume to value shift. The 2005 response rate, while ro- bust at 65%, is not as substantial as the 97% in 2015, and it is impossible to know if the non-responders differ from the responders in a manner

that would impact the conclusion. Finally, the limitations of the Nursing Minimum Data set are evident, as it is impossible to discern to complex- ity of the nursing role or if it is in a traditional or reimagined role in a redesigned system of care. Terms such as “ambulatory care” are not re- flective of the complexity and array of relevant workforce settings. Fu- ture research to address these limitations, including the potential development of an instrument that is sensitive to nuanced workforce changes, would create a valuable contribution to society.

Acknowledgments

Vermont AHEC Nursing Initiatives. AARP/RWJF Future of Nursing State Implementation Program grant

(#731Q9).

References

AACN (2006). The essentials of doctoral education for advanced nursing practice. Re- trieved from http://www.aacn.nche.edu/dnp/Essentials.pdf.

AACN (2008). The essentials of baccalaureate education for professional nursing practice. http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf Retrieved from http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf.

AACN (2011). The essentials of master's education in nursing. Retrieved from http:// www.aacn.nche.edu/education-resources/MastersEssentials11.pdf.

Bevill, J. W., Jr., Cleary, B. L., Lacey, L. M., & Nooney, J. G. (2007). Educational mobility of RNs in North Carolina: Who will teach tomorrow's nurses? A report on the first study to longitudinally examine educational mobility among nurses. The American Journal of Nursing, 107(5), 60–70 quiz 71 http://dx.doi.org/10.1097/01.naj. 0000268172.71477.99.

California Institute for Nursing and Health Care (2013). Nurse role exploration project: The affordable care act and new nursing roles. http://www.calhospital.org/sites/ main/files/file-attachments/cinhc_whitepapernurseroles.pdf Retrieved from http:// www.calhospital.org/sites/main/files/file-attachments/cinhc_whitepapernurseroles. pdf.

Centers for Medicare and Medicaid Services (2015). Retrieved from https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based- Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

Cleary, B., & Rice, R. (Eds.). (2005). Nursing workforce development strategic state initiatives. New York, NY: Springer Publishing Company.

Department of Vermont Health Access (2014). Vermont blueprint for health 2014 annual report. Retrieved from http://legislature.vermont.gov/assets/Legislative-Reports/ VTBlueprintforHealthAnnualReport2014-Final.2015.01.26.pdf.

Doran, K., Misa, E., & Shah, N. (2013). Housing as health care—New York's boundary- crossing experiment. New England Journal of Medicine, 369, 2374–2377. http://dx. doi.org/10.1056/NEJMp1310121.

Fraher, E. P., Ricketts, T. C., Lefebvre, A., & Newton, W. P. (2013). The role of academic health centers and their partners in reconfiguring and retooling the existing work- force to practice in a transformed health system. Academic Medicine, 88(12), 1812–1816. http://dx.doi.org/10.1097/acm.0000000000000024.

Jones-Bell, J., Karshmer, J., Berman, A., Prion, S., Van, P., Wallace, J., & West, N. (2014). Col- laborative academic-practice transition program for new graduate RNs in community settings: Lessons learned. Journal of Continuing Education in Nursing, 45(6), 259–264. http://dx.doi.org/10.3928/00220124-20140402-01.

Macy Foundation (2016). Registered Nurses: Partners in Transforming Primary Care. Con- ference Proceedings available at http://macyfoundation.org/docs/macy_pubs/201609_ Nursing_Conference_Exectuive_Summary_Final.pdf

Reimanis, C. L., Cohen, E. L., & Redman, R. (2001). Nurse case manager role attributes: Fif- teen years of evidence-based literature. Lippincott's Case Management, 6(6), 230–239 (quiz 240–232).

Schmitt, N. (2005). Role transition from caregiver to case manager, part 1. Lippincott's Case Management, 10(6), 294–302.

Squires, D. (2011). The U.S. health system in perspective: A comparison of twelve indus- trialized nations. Retrieved from http://www.commonwealthfund.org/~/media/ Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_ nations_intl_brief_v2.pdf.

University of Vermont AHEC (2013). Vermont primary care workforce 2013 snapshot. Retrieved from http://www.uvm.edu/medicine/ahec/documents/ AHEC2013PCReport2014_01_28_001.pdf.