by Shannon Hale
MHA, Quality Improvement Advisor


Nurses have always been role models, and we have the numbers to prove it. A recent Gallup poll showed that the American public views nursing as the most ethical profession for the 16th year in a row. That’s because nurses are viewed not only as caregivers, but also as teachers, companions and cheerleaders. From engaging patients and family members as part of the health care team to establishing new ways of working with patients to keep them well and functioning at their highest potential, nurses play an integral role as ambulatory practices prepare to succeed in the new arena created by value-based care.

Every day, we witness the ways that nurses are leading innovation and transformation efforts in the ambulatory setting. In line with value-based care, ambulatory practices are tasked with not only treating acute illnesses, but also with promoting optimal wellness and helping patients with chronic diseases manage their conditions such that they can avoid hospitalization or emergency care.  

Within the Transforming Clinical Practice Initiative (TCPI) and nationwide, we’re seeing interesting trends on how nurses are helping to reshape our health care system for the better. In addition to such things as performing wellness checks for high-risk patients, some other examples include:

  • Engaging patient and family members as part of the care team. In many hospitals, nurses – as part of the clinical team – review patient education materials, then patients proofread to ensure they were written in a health care literate format for all, covering topics important to the identified patient population. By including patients in this process, they are able to help ensure the documents are clear and easily understood by all.
  • Ensuring that patients have transportation to clinic appointments. Lack of transportation often is a reason for patients to cancel appointments or to not show for scheduled appointments. At several organizations, nurses connect patients to state-funded options for transportation (such as the Medicaid bus), helping to ensure that patients are able to get to their appointments and therefore increasing access to care.
  • Following up with patients who have been recently discharged from the hospital or emergency department. A call or visit by a nurse to a recently discharged patient can help answer questions the patient may have, help verify understanding of any discharge instructions and build a trusting relationship – reassuring them that the team is there to not only help them recover from illness, but also to help them reach optimal health.
  • Linking patients to community resources. Often, patients come to the ED for non-medical issues (think of the homeless patient who comes to the ED frequently complaining of headaches, when the true underlying cause of his headache is lack of access to food). At hospitals all over the U.S., nurses are working closely with other health care team members to connect patients with needed community resources such as food banks, dental clinics and homeless shelters.

These are just a few examples of how nurses across the country are embracing and preparing for success in the new value-based payment model. As we celebrate National Nurses Week next week, we not only thank nurses for all that they do for patients and their families, but also for all that they do as health care continues to transform and innovate.

About the author. In his role at Vizient, Shannon Hale delivers advisory services to assist clinicians participating in TCPI, aimed at transforming their practices to deliver higher quality care with cost savings. Prior to joining Vizient, Hale served as administrative director for the Levine Cancer Institute in Charlotte, NC, where he was responsible for overall system quality, laboratory operations, a live-answer call center, and a nursing project management team.

Published: May 2, 2018