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Evolving Practice of Nursing and Patient Care Delivery Models


The U.S. healthcare system is undergoing a transformation. The system is increasingly shifting from a curative system to a preventive patient-centric model. The healthcare reforms were introduced by the enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010. The nurses were among the most affected healthcare providers. Changing the healthcare landscape from curative-inclined to disease prevention and well-being model, the legislation conferred the role of leading the reforms on the nurses. To achieve the alterations, the nursing personnel and their practices will have to evolve to be in sync with the desired outcomes of the healthcare reforms. The paper will discuss the evolving practice of nursing and patient care delivery models and demonstrate the essential role that nurses are playing and are set to play in implementing the reforms.

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Continuity or Continuum of Care

A change that will be witnessed with the implementation of the healthcare reforms is that nurses will have broader contribution. This is envisaged in the concept of continuity of care. The continuity of care or continuum of care is a patient-oriented model of care that offers a comprehensive array of medical interventions (Timothy, 2015). It represents a shift from the episodic model of care that has for so long been the mainstay of the U.S. healthcare system. In case of the episodic model of care, patients are offered treatment only when they are sick, and it is mainly physiological (Mucenski & Smoker, 2015).

The healthcare providers do not make a follow-up or even attempt to form a relationship with a patient, even if the patient needs lifelong interventions. However, the shift to the seamless continuum of care will empower nurses, and other healthcare professionals, to embrace a holistic approach to patient treatment (Swearingen, 2013). Nurses will have to consider a host of factors including socio-economic well-being and social support systems among others when designing interventions. Additionally, nurses will pay their patients home visits to check on their progress and collaborate with other professionals to offer alternative medicine to improve patient outcomes. Crucially, nurses will have to evolve to become managers who facilitate continuity of care through managing their patients’ transition from one level or form of care to another (Timothy, 2015).

Accountable Care Organizations

Additionally, nursing practice is expected to evolve and become more collaborative. This is informed by the concept of Accountable Care Organizations (ACOs). The ACOs are healthcare providing groups that work collaboratively as teams to coordinate and deliver care to groups of patients (Mensik, 2013). The primary objective of ACOs is to provide patients with high quality, patient-centric care at the lowest prices possible. As Mensik (2013) observes, the ACOs bring together health specialists from different levels of health care to design interventions that promote health of the identified patient group. The ACOs are effective because the interdisciplinary and multidisciplinary teams can aggregate their efforts to provide the best care across the continuum of care through an integrated care approach. Therefore, the nurses’ role will expand from merely being providers of medical care to that of coordinators and collaborators in providing advanced levels of care. Their role will further be to act as communicators and quality managers in the community. This differs from the past practices when nurses were largely confined to healthcare institutions.

Patient-Centered Medical Homes

The establishment of Patient-Centered Medical Homes (PCMHs) further highlights the increasing role of nurses in providing holistic, comprehensive patient care. According to Sutter-Barrett, Sutter-Dalrymple, and Dickman (2015), PCMHs are healthcare institutions that provide coordinated, interdisciplinary, and inter-professional patient care. Therefore, the medical homes offer a wide array of medical interventions that have been designed through inter-professional and interdisciplinary consultative processes. The institutions embody the continuum of care approach to healthcare delivery. The teams working in the medical homes are comprised of APNs, RNs, physicians, palliative care specialists, psychologists, and many other healthcare specialists. The role of nurses in such settings, thus, expands beyond primary care provision to being teachers of patient self-management and care coordinators (Swearingen, 2013).

Employing the now out-of-favor, fragmented, episodic care delivery models, the nurses were largely viewed as and regarded as physicians’ assistants. They had no diagnostic powers. They also could not make or facilitate inter-professional collaborations to boost the health of their clients. However, with the initiated reforms, nurses have evolved to become not only the coordinators of care but also leaders (Muehlbauer, 2012). In states where the APRNs’ practices have been expanded sufficiently, nurses have opportunities to design and implement nurse-led care interventions (Fairman & Okoye, 2011). Through PCMHs, nurses can further enhance the application of health information technology, thus allowing for integrated care approach that was conspicuously absent among physicians.

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Nurse-Managed Health Clinics

The practice of nursing is also expected to grow to incorporate community-based primary and wellness care. Through the Nurse-Managed Health Clinics (NMHCs), nurses will be able to provide the underserved population with quality care regardless of their financial capabilities (Sutter-Barrett, Sutter-Dalrymple, & Dickman, 2015). The Nurse-Managed Health Clinics are healthcare institutions that primarily seek to provide patient care for free. This represents a shift from the unpopular fee-for-service model that has for long been applied by healthcare institutions, thus locking many people from accessing quality medical care. Through operating the NMHCs, nurses will serve as critical access points, especially for the underserved population (Sutter-Barrett, Sutter-Dalrymple, & Dickman, 2015). The implication is that everyone will be able to access quality care and cases of hospital readmissions will greatly reduce. Crucially, in the future, nurses will increasingly become self-sufficient. They will be able to control their practice and care delivery.

Being one of the healthcare institutions that have been identified for federal grants, NMHCs will be crucial in enhancing the quality of nursing services offered in care institutions. Through providing nursing placement opportunities for undergraduate and graduate students, the NMHCs will increase nurses’ competencies (Mucenski & Smoker, 2015). This is in sync with the recommendations of the Institute of Medicine Future of Nursing report that sought to increase nurses’ competencies. This was to be achieved by increasing the number of nurses with Bachelor’s degrees from 45% to 80% and double those with PhDs by 2020 (Muehlbauer, 2012). Crucially, the NMHCs will spur increased enrollment in nursing programs that will be vital for improving the quality of care. It will also be important because it will solve the nursing shortage that is projected to intensify by 2020. Therefore, the healthcare reforms provide an avenue for nurses to solve nursing shortage in the U.S. besides providing quality care.

Impressions of the Anticipated Changes in Healthcare Delivery

The Patient Protection and Affordable Care Act that was enacted in 2010 sought to introduce reforms in the ailing U.S. healthcare sector. The Act has immensely transformed the nursing practice as some of its provisions directly and indirectly influence how nurses will alter their professional activities. Therefore, the impressions of fellow nurses on the anticipated changes to healthcare delivery that would be effected through the healthcare reforms were investigated. The following is a summary of the feedback received and weighed against the findings and understanding of health reform.

One of the people that shared her thoughts about the presentation on the evolving practice of nursing and patient care delivery models was Anne, a fellow nursing colleague working with chronically ill persons. Anne expressed that she was particularly excited by the new roles accorded to nurses. Anne was especially thrilled by the fact that nursing practice was expanding beyond the walls of the healthcare institutions. The PPACA revolutionized the healthcare system that instead of being curative-inclined, it was expected to become preventive (Muehlbauer, 2012). Prior to its enactment, the healthcare system was mainly dealing with designing interventions that treated diseases and conditions to deliver primary care. However, the implementation of the reforms means that the healthcare institutions will be reserved for patients with acute cases. All the other patients whose cases are not serious will be treated at community-based healthcare institutions.

Anne has developed an impression that she will not have to work in the hospitals anymore, even though she is a Registered Nurse. Anne reckons that sometimes the hospital setting is limiting and possibly depressing. The healthcare reforms will ensure the higher frequency of nurse practices being employed beyond hospital walls, thus increasing their roles in the community, clinics, and medical homes (Mensik, 2013). The nurses will be able to take care of their patients at their homes because of the institutionalized nurse home visits. In the research, it has been established that one of the provisions of the PPACA that significantly influenced the progress of nursing practices is Section 2951 that authorizes nurse home visits (Mensik, 2013).

The provision establishes a federal grant fund that will be allow hospitals to implement nurse home visitation programs, especially for maternal, infant, and early childhood purposes. Even though the scope of application is limited, Anne reckons that the implications of the provision are far-reaching and revolutionary. Therefore, according to my colleague Anne, the implication is that nurses will increasingly employ alternative medicine and an integrative approach to care. Crucially, the interventions designed to promote the health of a client will not only consider the illness but other social factors that may affect the patient’s outcomes. Ultimately, nurses can offer relevant, quality, evidence-based interventions (Muehlbauer, 2012).

Another female colleague named Alicia had a bleaker outlook for the health reforms. According to Alicia, it was virtually impossible to implement the healthcare reforms without first streamlining the nursing practice and adapt it to the anticipated challenges. After listening to the presentation on the evolving nursing practices and patient care delivery models, Alicia dismissed the expected change as a pipe dream. She was under the impression that the anticipated evolution of nursing practice was purely theoretical, at least at that moment. She especially faulted the healthcare leaders who she described as ‘optimistic futurists’ for proposing and enacting reforms that were not comprehensive and thus impractical. Alicia, for instance, offered a rebuttal on the possibility of offering patient care at lower costs. She stated that as long as the nurse reimbursement programs were not streamlined, there was no chance such interventions would succeed. Alicia was under the impression that only after nurses received reimbursements directly to their accounts could the home visits and other outside interventions succeed.

Apart from the issue of reimbursements to facilitate care delivery beyond the healthcare institutions, Alicia also had reservations about the reforms in terms of the extent of their implementation. Alicia stressed that with the current restrictions on the scope of practice for nurses in most states in the U.S., it was virtually impossible for nurses to offer effective patient care across the whole continuum of care. In the research, it was established that in most states in the U.S., APRNs were not considered to be as qualified as physicians even though they were (Mensik, 2013). The Institute of Medicine Future of Nursing report recommended that nurses should be allowed to exploit their capabilities and skills fully (Muehlbauer, 2012).

However, most APRNs were still restricted to the drugs they could prescribe, especially the controlled ones. Alicia was under the impression that the continuity of care could not work so long as the nurses were merely viewed as physicians’ assistants. In most of the patient care models that envisaged the use of accountable care organizations, patient-centered medical homes and nurse-managed health clinics, nurses had coordinating and leadership roles. If their authority and capabilities were not ascertained in the health institutions, Alicia opined that the same might as well be expected in the anticipated collaborations through interdisciplinary and multidisciplinary teams.

The third colleague, Andre, was similarly thrilled with the anticipated changes in the healthcare delivery and the new roles of nurses. The shift of focus to preventive care would mean that the nurses would have a greater role to play in providing high quality patient care. Through collaboration with other professionals in the field, nurses would have an enhanced role in developing up-to-date, evidence-based nursing interventions (Korner, 2010). The PPACA introduced federal grants to be used to promote nursing education and competencies in nursing practice. Section 5301 of the PPACA provides that a grant program for hospitals, medical schools and training programs for physician assistants be established. The grant will help the nurses and other healthcare providers advance their knowledge through furthering their education. Andre rightly established that the implication was that the quality of care would improve since more and more nurses would enhance their competencies. This provision was also in sync with the recommendations of Institute of Medicine Future of Nursing report. The report sought to increase the number of nurses with Bachelor’s degree and PhD by 2020 (Muehlbauer, 2012).

Andre, who himself aspires to advance beyond his Bachelor’s degree, is under the impression that the health reforms can only be achieved through improved nursing education and competencies. Consequently, nurses will better discharge their coordinating roles and make diligent follow-ups on chronically ill patients. Additionally, nurses will better understand and appreciate the dynamics that influence care delivery beyond the hospital setting that will further enhance the development of patient-centric care.

In summary, there were mixed reactions to the presentation. Anne reckoned that nurses were the drivers of health care reforms; expanding their roles outside the hospital setting would not only facilitate the provision of high quality patient care but also enable it at lower costs. Alicia had a bleaker outlook of the reforms suggesting that they could only be effective if the changes were effected in nursing practice before aggregating the whole health care system. Lastly, Andre appreciated the increased roles of nurses in facilitating interdisciplinary and multidisciplinary coordination and designing evidence-based nursing interventions. He was sure that improving nursing education and competencies of the nursing workforce would be crucial in transforming the health system from curative to preventive, patient-centered care delivery model. The underlying impression was that nurses needed to evolve with the progressing health system.


In conclusion, it is evident that the healthcare reforms proposed will impact nursing practice significantly. Nurses are the drivers of the anticipated change, and consequently, nursing practices will also have to evolve to mirror the reforms. Institutions such as Accountable Care Organizations, Patient-Centered Medical Homes, and Nurse-Managed Health Clinics will transform nursing practice and situate it within the community rather than within the walls of healthcare institutions. Crucially, the patient delivery models will also evolve to become more preventive, patient-centered, and integrated with their care delivery approach. Therefore, nurses should evolve and embrace these anticipated changes to better implement the healthcare reforms.

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