THE ESSENCE OF NURSING ASSIGNMENT

December 27, 2022

THE ESSENCE OF NURSING ASSIGNMENT

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THE ESSENCE OF NURSING ASSIGNMENT

T here are transformative changes occurring in healthcare for which nurses, because of their role, their education, and the respect they have earned, are well positioned to contribute to and

lead. To be a major player in shaping these changes, nurses must understand the factors driving the change, the mandates for practice change, and the competencies (knowledge, skills, and attitudes) that will be needed for personal and systemwide success. This article discusses the driving factors leading to healthcare transformation and the role of the registered nurse (RN) in leading and being a fully contributing member of the interprofes- sional team as we shift from episodic, provider-based, fee-for-service care to team-based, patient-centered care across the continuum that provides seamless, affordable,

Factors driving healthcare transformation include fragmen- tation, access problems, unsustainable costs, suboptimal outcomes, and disparities. Cost and quality concerns along with changing social and disease-type demographics cre- ated the greatest urgency for the need for change. Caring for and paying for medical treatments for patients suffering from chronic health conditions are a signifi cant concern. The Affordable Care Act includes programs now led by the Centers for Medicare & Medicaid Services aiming to improve quality and control cost. Greater coordination of care—across providers and across settings—will improve quality care, improve outcomes, and reduce spending, es- pecially attributed to unnecessary hospitalization, unneces- sary emergency department utilization, repeated diagnostic testing, repeated medical histories, multiple prescriptions, and adverse drug interactions. As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. Nurses are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team as we shift from episodic, provider- based, fee-for-service care to team-based, patient-centered care across the continuum that provides seamless, afford- able, and quality care. These shifts require a new or an enhanced set of knowledge, skills, and attitudes around wellness and population care with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement.

Healthcare Transformation and Changing Roles for Nursing

Susan W. Salmond ▼ Mercedes Echevarria

Susan W. Salmond, EdD, RN, ANEF, FAAN, Professor & Executive Vice Dean, Rutgers University School of Nursing, Westfi eld, NJ.

Mercedes Echevarria, DNP, RN, APN, Associate Dean of Advanced Nursing Practice & Assistant Professor, Rutgers University School of Nursing, Monroe Twonship, NJ.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

The authors have no confl ict of interest to declare.

DOI: 10.1097/NOR.0000000000000308

and quality care. This new health paradigm requires the nurse to be a full partner in relentless efforts to achieve the triple aim of an improved patient experience of care (including quality and satisfaction), improved outcomes or health of populations, and a reduction in the per cap- ita cost of healthcare.

Driving Forces for Change: Cost and Quality Concerns Table 1 provides an overview of key factors that have been driving healthcare reform. Unsustainable growth in healthcare costs without accompanying excellence in quality and health outcomes for the U.S. population has been escalating to the point at which federal and state budgets, employers, and patients are unwilling or una- ble to afford the bill ( Harris, 2014 ). The United States spends more on healthcare than any other nation. In fact, it spends approximately 2.5 times more than the average of other high-income countries. Per capita health spending in the United States was 42% higher than Norway, the next highest per capita spender. In 2014, U.S. health care reached $3.0 trillion, or $9,523 per person ( Centers for Medicare & Medicaid Services [CMS], 2014 ). This is almost 20% of the gross domestic product (GDP), meaning that for every $5 spent in the federal budget, about $1 will go to healthcare. The larg- est expenditures are for hospital care (about 32%), phy- sician and clinical services (26%), and prescription drugs (10%) ( CMS, 2015 ). With the demographic shifts in the aging population and those with chronic illness, it is anticipated that in three short years, healthcare spending will reach $4.3 trillion ( George & Shocksnider, 2014 , p. 79; Hudson, Comer, & Whichello, 2014 , p. 201).

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TABLE 1. DRIVERS OF CHANGE Cost • More resources are devoted to healthcare per capita in the United States than in any

other nation. Comparing with others, GDP spending for health is 16.2% in the United States, followed by 10.9% in Switzerland, 10.7% in Germany, 9.7% in Canada, and 8.5% in the United Kingdom ( George & Shocksnider, 2014 ).

• Healthcare spending in the United States is 4.3 times greater than the amount spent on the national defense.

• Healthcare spending is projected to reach $4.3 trillion by 2017 (19.5% of GDP) and $4.6 trillion (19.8% of GDP) by 2020 ( George & Shocksnider, 2014 , p. 79; Hudson et al., 2014 , p. 201).

• The rapid increase in healthcare spending in the United States over the past two dec- ades and its anticipated growth in the coming years can be tied inextricably to the increasing number of people with multiple chronic illnesses. It is estimated that 75% of the more than $2.5 trillion we spend annually on healthcare are related to chronic diseases ( CDC, n.d.-a ; Thomas, 2012).

Waste • 30 cents of every dollar spent on medical care in the United States is wasted, amount- ing to $750 billion annually. Contributing to this is inefficient delivery of care, exces- sive administrative costs, unnecessary services, inflated prices, prevention failures, and fraud ( Berwick & HackBerth, 2012 ; Mercola, 2016 ).

Variability and lack of standardization

• The Dartmouth Atlas of Health Care report documents the variations in practice pat- terns/care, healthcare costs, and patient outcomes by individual practitioners, geo- graphical regions, type of insurance coverage, and type of condition ( http://www.dar- mouthatlas.org/ ) and reports significant variability in practice patterns/care and cost.

• The Blue Cross Blue Shield (2015) study of cost variations for knee and hip replace- ment surgical procedures in the United States found similar cost variability—for exam- ple, in the Dallas market, a knee replacement could cost between $16,772 and $61,585 (267% cost variation) depending on the hospital ( Blue Cross Blue Shield, 2015 ).

• Autonomy (the right, and obligation, to use your knowledge, skills, and judgment in the manner you believe is best for your patient, within evidence-based accepted prac- tice limits) is stressed over standardization. Yet, there are care protocols and other types of evidence-based processes where greater efficiencies and safer outcomes result from standardized work (central line protocols, wound care, perioperative use of pro- phylactic antibiotics, deep vein thrombosis protocols; Leape, 2014 , p. 1571).

Quality • The U.S. health system ranks last or next to last compared with six other nations (Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom) on five dimensions of high-performance health system: quality, access, efficiency, equity, and healthy lives ( Hudson et al., 2014 , p. 202).

• Fragmented system with recurring communication failures. • Nonbeneficial or redundant healthcare tests and services. • Unacceptable risk of error. • Despite higher level of spending, the hospitals in the United States documented to

readmit an average of one fifth of Medicare patients within 30 days after discharge. Reports indicate that 19.6% of the 11.8 million Medicare beneficiaries discharged from a hospital in 2009 were rehospitalized within 30 days and 34% within 90 days, where- as 25% of Medicare patients discharged to long-term care facilities were readmitted to the hospital within 30 days ( Enderlin et al., 2013 , p. 48).

Healthcare system infrastructure

• The system puts an emphasis on specialization and professionalism, while clearly essential, tends to result in people working in ‘‘silos’’ where individuals often perform at high levels of ability but sometimes interact little or ineffectively with those in other disciplines ( Leape, 2014 , p. 1570).

• Most healthcare organizations have a hierarchical structure that inhibits communica- tion, stifles full participation, and undermines teamwork ( Leape, 2014 ).

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The high cost of care is, in part, driven by the greater use of sophisticated medical technology, greater con- sumption of prescription drugs, and higher healthcare prices charged for these procedures and medications ( The Commonwealth Fund, 2015 ). Also contributing to high cost is waste. It is estimated that 30 cents of every dollar spent on medical care in United States is wasted, amounting to $750 billion annually. Components of waste include ineffi cient delivery of care, excessive ad- ministrative costs, unnecessary services, infl ated prices, prevention failures, and fraud ( Berwick & HackBerth, 2012 ; Mercola, 2016 ).

Not only are the prices for procedures signifi cantly higher in the United States but also the charges for similar procedures vary dramatically, even within the same geographic locale. Reporting on the variability

in healthcare charges for similar procedures, The Washington Post ( Kliff & Keating, 2013 ) conveyed the federal government’s release of the prices that hospi- tals charge for the 100 most common inpatient proce- dures ( CMS, 2013 ). The numbers revealed large, seemingly random variation in the costs of services. For joint replacements, the most common inpatient surgery for Medicare patients, prices ranged from a low of $5,304 in Ada, OK, to $223,373 in Monterey Park, CA. The average charge across the 427,207 Medicare patients’ joint replacements was $52,063. Looking at cost variation in a smaller geographic area, the Blue Cross Blue Shield (2015) study of cost variations for knee and hip replacement surgical pro- cedures in the United States found similar cost vari- ability. In the Dallas market, a knee replacement

TABLE 1. DRIVERS OF CHANGE ( CONTINUED )

Mistargeted incentives— Reimbursement

• The financial incentives for both providers and patients in fee-for-service systems tend to encourage the adoption of more expensive treatments and procedures, even if evi- dence of their relative effectiveness is limited (Orszag & Ellis, 2007).

• The fee-for-service system provides “incentives for overuse and disincentives (i.e., little or no compensation) for preventive, coordinated, and comprehensive care” ( Leape, 2014 , p. 1571).

• These financial and structural incentives restrict potential for better patient care out- comes and effective resource allocation.

Aging demograph- ics and increased longevity

• The older population—persons 65 years or older—numbered 44.7 million in 2013 or 14.1% of U.S. population, one in every seven Americans ( Administration on Aging, n.d. ).

• Those 65 years and older will grow to 21.7% of the population by 2040. By 2060, there will be about 98 million older persons, more than twice their number in 2013. The fastest growing group is those older than 85 years.

• Older adults transitioning between hospital units and settings often experience incon- sistent nursing care and more adverse care incidents such as nosocomial infections, delirium, falls, and medication errors ( Enderlin et. al, 2013 ).

• The frequent transition of older people between health services, social, and commu- nity care providers upon discharge from inpatient care to home increases risk of adverse incidents, poor health, and social outcomes (Allen, Ottmann, & Roberts, 2013, p. 254).

Chronic illness • Noncommunicable diseases such as diabetes, heart disease, stroke, and cancer are now the leading cause of death in the world (Lytton, 2013). It requires more than a focus on acute illness but behavioral approaches to modify risk factors including poor diet, obesity, and inactivity.

• 44% of the noninstitutionalized U.S. population (55 million people) is estimated to have two or more chronic conditions, 85% of adults aged 65 years and older have at least one chronic disease, and 62% have two or more chronic diseases (Wertenberger, Yerardi, Drake, & Parlier, 2006).

• Two thirds of Medicare spending attributed to patients with five or more chronic illnesses. • Medicare fee-for-service spending accounts for more than three fourths of the total

Medicare spending. • Incidence of chronic illness projected to grow with aging demographics and rising

obesity epidemic.

Healthcare disparities

• High rates of preventable diseases among racial and ethnic minorities. • Among African Americans, the cost burden of three preventable diseases, high blood

pressure, diabetes, and stroke, was $23.9 billion in 2009. By 2050, this is expected to increase to $50 billion a year (The Urban Institute, 2009).

• Latinos receive worse care than non-Latino Whites for about 60% of core measures ( AHRQ, 2011 )

Note . GDP = gross domestic product.

could cost between $16,772 and $61,585 (267% cost variation) depending on the hospital ( Blue Cross Blue Shield, 2015 ).

Perhaps, if this outrageous price tag bought value, we as a nation would accept the expense. After all, healthcare is more vital than most other goods or services. However, the stark reality is that despite outspending all other com- parable high-income nations, our system ranks last or near last on measures of health, quality, access, and cost. The United States has higher infant mortality rates, higher mortality rates for deaths amenable to healthcare (mortality that results from medical conditions for which there are recognized healthcare interventions that would be expected to prevent death), higher lower extremity amputations due to diabetes, higher rates of medical, medication, and laboratory errors, and higher disease burden, as measured by “disability-adjusted life-years,” than comparable countries ( Peterson-Kaiser Health Tracker System, 2015 ).

Examining quality within the system, we know that our healthcare system is fragmented with recurring communi- cation failure and unacceptable levels of error. The system is diffi cult to navigate, especially when patients and car- egivers are asked to seek care across multiple providers and settings for which there is little to no coordination. There are signifi cant barriers to accessing care, and this problem is disproportionately true for racial and ethnic mi- norities and those with low-socioeconomic status ( Agency for Healthcare Research and Quality [AHRQ], 2011 ). With a focus almost exclusively on acute care, the primary care system in the United States is in disarray or, for some, non- existent despite research data that associate access to pri- mary care with lower mortality rates and lower overall healthcare costs ( Bates, 2010 ). It is not surprising therefore that when discharged from the hospital, an average of one in fi ve Medicare patients (20%) was readmitted to the hos- pital within 30 days after discharge in 2009 and 34% were readmitted within 90 days. Moreover, 25% of Medicare pa- tients discharged to long-term care facilities were readmit- ted to the hospital within 30 days, clearly representing gaps in care coordination ( Enderlin et al., 2013 , p. 48).

The absence or underuse of peer accountability, un- derdeveloped quality improvement infrastructures, lack of accountability for making quality happen, in- consistent use of guidelines and provider decision-sup- port tools, and lack of clinical information systems that have the capacity to collect and use digital data to improve care all contribute to quality care issues ( Shih et al., 2008 ). Another impediment to quality is the hier- archical structure of most healthcare organizations that “inhibits communication, stifl es full participation, and undermines teamwork” ( Leape, 2014, p. 1570 ). Failure of these organizations to adopt and enforce “no tolerance” policies for behaviors that are known to im- pact quality (i.e., disrespectful, noncollaborative care among team members that impedes safety to ask ques- tions and express ideas; failure to comply with basic care approaches such as hand washing hygiene and time-out protocols that are known to decrease safety risk) perpetuates the dysfunctional culture in health- care where negative behaviors block progress toward quality ( Leape, 2014 ).

Driving Factors for Change: Changing Demographics Changing social and disease-type demographics of our citizens is also fueling the mandate for change. The de- mographer James Johnson coined the phenomenon “the browning of America” to illustrate that people of color now account for most of the population growth in this country. People of color face enduring and long-standing disparities in health status including access to health coverage that contributes to poorer health access and outcomes and unnecessary cost. The AHRQ in its annual National Healthcare Quality and Disparities Report has provided evidence that racial and ethnic minorities and poor people face more barriers to care and receive poorer quality of care when accessed. These facts under- score the imperative for change in our system.

The graying of America is another changing social demographic, with signifi cant healthcare implications. Beginning January 1, 2011, the oldest members of the Baby Boom generation turned 65. In fact, each day since that day, today, and for every day for the next 19 years, 10,000 Baby Boomers will reach the age of 65 years ( Pew Research Center, 2010 ). Currently, just 14.1% of the U.S. population (44.7 million) is older than 65 years. By 2060, this fi gure will be 98 million or about twice their current number ( Administration on Aging, n.d. ). This shift will have signifi cant economic conse- quences on Social Security and Medicare.

Overlapping with the changing social demographics is the change in disease-type demographics due to the fact that there is a rise in chronic disease among Americans and signifi cantly so among older Americans. Chronic disease (heart disease, stroke, cancer, Type 2 diabetes, obesity, and arthritis) is the leading cause of death and disability for our citizens, affecting an esti- mated 133 million people. Thought of by some as the single biggest force threatening U.S. workforce produc- tivity, as well as healthcare affordability and quality of life, chronic diseases are among the most “common, costly, and preventable of all health problems” ( Centers for Disease Control and Prevention [CDC], n.d.-b ). Those with chronic conditions utilize the greater num- ber of healthcare resources, accounting for 81% of hos- pital admissions, 91% of prescriptions fi lled, 76% of all physician visits, and more than 75% of home visits ( Partnership to Fight Chronic Disease, n.d. ). Not sur- prisingly, older people are more likely to have more co- morbidities. Eighty-fi ve percent of adults aged 65 years have at least one chronic disease, 62% have two or more chronic diseases, and 23% have fi ve or more chronic conditions, and these 23% account for two thirds of all Medicare spending ( Volland, 2014 ).

The situation becomes even more serious when the person also has a disability or activity limitation. Our episodic healthcare model is not meeting the needs of people with chronic conditions and often leads to poor outcomes ( Anderson, 2010 ). More than a quarter of peo- ple with chronic conditions have limitations when it comes to activities of daily living such as dressing and bathing or are restricted in their ability to work or attend school. The number of people with arthritis is expected

to increase to 67 million by 2030 and of these 25 million will have arthritis-attributable activity limitations ( CDC, n.d.-a ). These numbers are conservative, as they do not incorporate the current obesity trends that are likely to add to future cases of osteoarthritis. A signifi cant chal- lenge, both now and for the future, is how to care for and pay for the care—medical treatment and other support- ive services—that people with chronic conditions need.

Voluntary Change Is Not Enough As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. With the turn of the century and the Institute of Medicine (IOM) reports, To Err Is Human: Building a Safer Health Care System and Crossing the Quality Chasm , we became increasingly aware that the level of unintended harm in medicine was too high and that there was a compelling need to scrupulously examine and transform systems to make healthcare safer and more reliable. The recom- mendations in Crossing the Quality Chasm ( IOM, 2001 ) called for adopting a shared vision of six specifi c aims for improvement that must be the core for healthcare (see Table 2 ). Although, in principle, there was agree- ment that these six aims were critical for an improved and effective system and should be evident across all set- tings, the reality is that widespread change did not occur. As suggested in the report, there was an immense divide between what we knew should be provided and what ac- tually was provided. This divide was not a gap but a chasm, and it was believed that the healthcare system as it existed was fundamentally unable to achieve real im- provement without a major system overhaul.

Enter Healthcare Reform Continued skyrocketing of healthcare costs, less than impressive heath status of the American people, safety and quality issues within the healthcare system, grow- ing concerns that cost and quality issues would inten- sify with changing demographics, and the reality that there were 50 million Americans uninsured and 40 mil- lion underinsured in the United States ushered in the Patient Protection and Affordable Care Act of 2010 ( Salmond, 2015 ). The Affordable Care Act (ACA) is more than insurance reform and greater access for the newly insured but includes programs now led by the CMS aiming to improve quality and control costs—what is being termed value. Value is in essence a ratio, with

quality and outcomes in the numerator and cost in the denominator ( Wehrwein, 2015 ).

Improving value means “avoiding costly mistakes and readmissions, keeping patients healthy, rewarding qual- ity instead of quantity, and creating the health informa- tion technology infrastructure that enables new payment and delivery models to work” (Burwell, 2015). Through the ACA and the power vested in the CMS to implement value, we are shifting to new principles underlying reim- bursement and new models for care and payment (see Table 3 ). For a while, healthcare, like a seesaw, will balance in a precarious state of transition from the old to the new ( Cipriano, 2014 ); however, no one is expecting a return to the old approaches of payment and care. In fact, it is expected by 2018 that 50 cents of every Medicare dollar will be linked to an identifi ed quality outcome or value (Burwell, 2015). And as the nation’s largest insurer, Medicare leads the way in steering new programs and setting the precedent for other private insurers.

As illustrated in Table 4 , these new models are shift- ing the paradigm of care from a disease model of treat- ing episodic illness, without attention to quality out- comes, to a focus on health and systems that reward providers for quality outcomes and intervening to pre- vent illness and disease progression—in keeping popu- lations well. Quality will be defi ned in terms of measur- able outcomes and patient experience at the individual and population levels, and payments (penalties and in- centives) will be calculated on the basis of the outcomes. Effi ciency will be maximized by reducing waste, avoid- ing duplicative care, and appropriately using special- ists. Outcomes will be tracked over longer periods of time—making care integration and care across the con- tinuum a mandate. Institutions and providers will be incentivized for keeping people well so as not to need acute hospital or emergency department (ED) service, for meeting care and prevention criteria, and for ensur- ing the perceived value of the healthcare experience or patient satisfaction is high. This forces a shift from a provider-centric healthcare system where the provider knows best to a delivery system that is patient-centric and respectfully engages the patient in developing self- management and behavioral change capacity. Funds have been made available through the ACA via the CMS to help providers invest in electronic medical records and other analytics needed to track outcomes and to provide support in developing the skills and tools needed to improve care delivery and transition to alternative payment models ( McIntyre, 2013 ).

TABLE 2. SIX AIMS FOR IMPROVEMENT FROM CROSSING THE QUALITY CHASM 1. Safe . Safety must be a system property of healthcare where patients are protected from injury by the system of care that is intended to

help them. Reducing risk and ensuring safety require a systems focus to prevent and mitigate error.

2. Effective . Care and decision making must be evidence based with neither underuse nor overuse of the best available techniques.

3. Patient-centered . Care must be respectful and responsive of individual patient’s culture, social context, and specifi c needs, ensuring that patients receive the necessary information and opportunity to participate in decisions and have their values guide all clinical decision mak- ing about their own care.

4. Timely . The system must reduce waits and harmful delays.

5. Effi cient. The system must avoid waste, including waste of equipment, supplies, ideas, time, and energy.

6. Equitable. Care must be provided equitably without variation in quality because of personal characteristics such as race, gender, ethnicity, geographic location, and socioeconomic status.

TABLE 3. NEW APPROACHES, PROGRAMS, AND MODELS SUPPORTED BY THE ACA The new principles for payment

Pay for Performance (P4P) P4P is the basic principle that undergirds new models of care being supported by the ACA. In these models, providers are rewarded for achieving preestablished quality metrics. The quality metrics for acute care organizations targets the experience of care (HCAHPS), processes of care (such as processes to reduce healthcare-associated infections and improve surgical care), effi ciency, and outcomes (i.e., rates of mortal- ity, surgical site infections). In the ambulatory care area, quality performance may be determined by any of the HEDIS measures. The key point for practitioners is total familiarity with how quality is being defi ned and measured. Knowing this allows for full participation in what must be done to achieve the quality.

Value-Based Purchasing (VBP)

This approach switches the traditional model of healthcare fee structure from fee-for-service where reim- bursement is for the number of visits, procedures, and tests to payment based on the value of care deliv- ered—care that is safe, timely, effi cient, effective, equitable, and patient-centered. In VBP, insurers such as Medicare set annual value expectations and accompanying incentive payment percentages for each Medicare patient discharge. The purchasers of healthcare are able to make decisions that consider access, price, quality, effi ciency, and alignment of incentives and can take their business to organizations/provid- ers with established records for both cost and quality (Aroh, Colella, Douglas, & Eddings, 2015).

Shared Savings Arrangements

Approaches to incentivize providers to offer quality services while reducing costs for a defi ned patient popu- lation by reimbursing a percentage of any net savings realized. Medicare has established shared savings programs in the PCMH and ACO models of care.

New programs and models of delivery and payment

Hospital-Acquired Condition Reduction Program

Under the ACA, Medicare payments for hospitals that rank in the lowest performing quartile for conditions that are hospital-acquired (i.e., infections [central line-associated bloodstream infections and catheter-as- sociated urinary tract infections], postoperative hip fracture rate, postoperative sepsis rate, postoperative pulmonary embolism, or deep vein thrombosis rate) will be reduced by 1%. Upcoming standards will be expanded to include methicillin-resistant Staphylococcus aureus infections ( CMS, , n.d. ).

Hospital Readmissions Reduction Program

Aimed at reducing readmissions within 30 days of discharge (readmission that currently cost Medicare $26 billion per year). To reduce admissions, hospitals must have better coordination of care and support. Hospitals with relatively high rates of readmissions will receive a reduction in Medicare payments. These penalties were fi rst applied in 2013 to patients with congestive heart failure, pneumonia, and acute myocardial infarction. The CMS added elective hip and knee replacements at the end of 2014 (Purvis, Carter, & Morin, 2015).

In time, 60-, 90-, and 190-day readmissions will be examined.

Accountable Care Organizations (ACOs)

The ACO is a network of health organizations and providers that take collective accountability for the cost and quality of care for a specifi ed population of patients over time. Incentivized by shared savings ar- rangements, there is a greater emphasis on care coordination and safety across the continuum, avoiding duplication and waste, and promoting use of preventive services to maximize wellness.

Better coordinated, preventive care is anticipated to save Medicare dollars, and the savings will be shared with the ACO. It is estimated that ACOs will save Medicare up to $940 million in the fi rst 4 years (Sebelius, 2013).

Patient-Centered Medical Homes (PCMHs)

PCMHs is an approach to delivery of higher quality, cost-effective, primary care deemed critically important for people living with chronic health conditions. Medical homes share common elements including com- prehensive care addressing most of the physical and mental health needs of clients through a team-based approach to care; patient-centered care providing holistic care that builds capacity for self-management through patient and c

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THE ESSENCE OF NURSING ASSIGNMENT

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