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f you didn’t know better, you might think Marla Salmon runs a business school. She talks about the future in terms of “systems of partnerships,” and of managers who use “technological interfaces and virtual resources.”
     But because she heads the nursing school and the system she refers to is health care, you realize that what she is really saying is, in the coming years, people largely will be in charge of their own health. And the partners and managers needed to help them do this will be nurses.
     Today’s stressed model of acute health care—replete with high costs, inadequate care for many, nursing shortages, and changing demographics—will need to be replaced by managed, preventive, and coordinated care, she believes. Nurses will increasingly move from their often supportive roles to serving as care leaders in this new model. And with luck and good planning, a large portion of the care for chronic or acute illnesses now provided in expensive hospitals will shift to proactive health management practiced within communities and families.
     “I think in the future, managed care will come to mean something positive and describe a situation in which care management rests more on the patient, with the nurse as coach,” says Salmon.
     The concept is easiest to see in the distant future, when a person’s own genetic barcode will reveal early on which diseases he or she might be most susceptible to. Nurses, who have long seen their role as educator, will serve as a focal point for connecting medical science with the health experience of individuals and families. Nurses will serve as guides, coaches, advocates, and resource experts, enabling people to take a more active role in managing their own health and health care. “We will be health partners who help people define and act to reach their best health,” Salmon says, adding with a laugh, “I see this as a bit like developing a financial plan for money management.”
     Like a broker putting dollars into investment accounts where they will best perform, the nurse of the future will be the “interface” between patients and resources that include physicians, specialists, diagnosticians, advanced technology, and mountains of e-health information. “Nurses will help personalize all those choices, both from the standpoint of determining what the individual wants and needs and then making sure it actually works for the person,” she says.
     Nurses will also be responsible for helping family members learn to care for ill loved ones.
     “The care team has to become everybody, not just those who are trained to be care providers,” Salmon says.
     “Say I have a diabetic child, a mother with Alzheimer’s disease, and I have high blood pressure and am pregnant,” she says. Currently, health care for such a family would consist of numerous visits to both primary care physicians and specialists for this particular condition or that. In the future, however, a nurse would provide “more of a global overview of my family’s health.
      “There would be someone that I could talk to about what I have learned about all this. And someone who could say to me, ‘Let’s talk about your family’s health—the things you are dealing with,’” Salmon says. “We would work together on a family program to help guide my decisions and give me all the information I need. For example, with respect to my mother’s Alzheimer’s disease, a nurse would help my family and me understand each stage of her disease, what we should expect, and what we will need to cope with it. She would outline how she could help.”
     “The nurses of the future will be what they have always been—the educator—but they will also be the integrator, the guide, the coach, and the advocate of patients and their families,” says Salmon.
     Nurses will also assume leadership roles in hospitals and in the myriad of other businesses and organizations that surround the health care Goliath—insurance companies, the biomedical industry, and government health policy makers, she says.
Who's the boss?  
Fundamental to realizing this future role of nursing is the education that takes place today. At the Nell Hodgson Woodruff School of Nursing, Salmon says, the goal has been to educate cutting-edge partners in patient care as well as research. “We make it very clear to our students that if they want to come to Emory, their job as nurses will be not to just provide care but also to improve the system of care in which we function.”
     “We have a strong focus on critical thinking and skills to help nurses be lifelong learners and leaders,” she says. “Many of our students come with liberal arts and humanities backgrounds, which help them understand nursing in the context of the larger world and how they as nurses can be relevant in that world.”
     Faculty also practice what they teach. Kathy Matthews, instructor in the Department of Family and Community Nursing, is collaborating with Richard Gitomer, assistant professor in the School of Medicine and medical director of primary care at Emory Crawford Long Hospital, on a project to improve care for the chronically ill. They have been funded by the Robert Wood Johnson Foundation to participate in a national program to create a new model for managing chronic conditions, starting in the academic setting. Matthews’ and Gitomer’s pilot program is for patients with diabetes and mirrors the team approach that Salmon describes.
     “In our current system of care, a patient usually sees a physician and the physician refers the patient to a specialist to treat a specific problem,” says Matthews. “It is a system of being farmed out, a system that right now is geared to people with acute problems, not to patients with chronic problems who need answers to questions that arise between appointments.
     “In this program, patients with chronic health problems enter into lifelong learning about their illness—a process that is not addressed in acute care,” she says. “If you don’t talk to people about the kind of journey they are taking, people revert automatically to the acute care model, and they don’t have as much of a chance to take control of their health care.
     “They then become controlled by the disease itself,” Matthews says. “You see that a lot. The system provides neither the time nor the structure for learning to occur, and we aim to correct that.”
     To address such issues, Matthews and Gitomer have convened a diabetes health team. All patient records are available electronically and monitored regularly by team members, who hold regular group discussions with patients. The nurse practitioner is on a level playing field with other health professionals to work with patients on lifestyle issues and collaborate as needed with physician team members to address the technical aspects of diabetes treatment. And Matthews points out, “In fact, it may be the nurse, or even the patient, who decides when to consult with a physician or another member of the care team.”
     The care model is based on the concept of a “proactive, prepared team” of health care providers who work to empower patients, explains Gitomer.
     “One of the goals in developing the team is to have all members function to the highest level of their training or licensure,” he says. “There is an emphasis on capitalizing on each member’s strengths, rather than the hierarchical relationship that exists in many health care settings.”

'No one is God in this system anymore'  
Graduate nursing student Lauren Thomas is already working in this new care model. Enrolled in the school’s women’s health/adult nurse practitioner program, Thomas is working in the clinic setting with Gitomer and another physician, Juliet Mavromatis, caring for patients with diabetes.
     “Typically, I see the patients before Dr. Gitomer or Dr. Mavromatis, and then we collaborate to provide care,” Thomas explains. “In addition to the initial examination, the patients complete a self-assessment form that helps them take ownership of their disease and make decisions along with their care providers. Many of the patients we see have hypertension and hyperlipidemia, along with the diabetes, and all of these conditions require continuous monitoring.”
     Beyond a shift in the balance of power in nurse-physician relationships, the care model moves the focus from the providers to the patient, says Gitomer.
     “The traditional model was that the source of the care comes from the providers who manage the care,” he says. “This model is designed to place the patient at the center. The care team facilitates the patient caring for himself or herself to the highest level of ability.”
     In that regard, Salmon points out that the traditional relationship between nurses and physicians in medical care has changed in recent years. “I don’t think anybody is God in this system anymore,” she says. “My view is that physicians and nurses are in many ways sharing a common ground—a commitment to the well-being of patients, families, and communities, and addressing concerns about quality and safety that the rest of the health care system is struggling to even keep in view.”
     Maureen Kelley, chair of the Department of Family and Community Nursing, is already demonstrating how a collaborative team approach to prenatal care can have dramatic results and redefine the experience for those involved. In this program, “Centering Pregnancy,” a group of expectant parents meet 10 times after the first three months of pregnancy. Instead of the usual 15-minute visit to a provider once a month (in which nurses play a supporting role), prenatal care, education, and support are rolled together in this setting.
     At Emory Crawford Long and Grady hospitals, Emory nurse-midwives lead two-hour sessions in which the women first complete a self-assessment, which includes checking their own blood pressure and weight and recording fetal heartbeat. Then everyone participates in a general discussion of issues of importance to their health and future family life. “It empowers nurses because it allows us to offer both in-depth education and care in the same space—we function as coaches in a process that fundamentally belongs to the pregnant couple and family. And it empowers parents as well, because they are interacting and sharing knowledge with each other,” Kelley says.
     Studies of similar initiatives nationwide have shown that mothers who participate in group-centered prenatal care have lower rates of complications, use of drugs, and other medical interventions and report higher rates of satisfaction with the experience.
     Kelley and Salmon see the program as a model on which to base preventive health care in the society at large. “We are a country in which the biggest health issues are those that are often based on behavior, such as the choices we make to smoke or exercise,” Kelley says. “With their passion for education, nurses are ideally suited to impact the health of the country at a place where it is most important, and that is in the home and community.”

Renee Twombly is a freelancer writer.


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