There is a great deal of geographic variation in where primary care providers work. About 65 million Americans live in areas that are officially identified as primary care shortage areas according to the Health Resources and Services Administration (HRSA) (Rieselbach et al., 2010). For example, while one in five U.S. residents live in rural areas, only one in ten physicians practice in those areas (Bodenheimer and Pham, 2010). A 2006 survey of all 846 federally funded community health centers (CHCs) by Rosenblatt and colleagues (2006) found that 46 percent of direct care providers in rural CHCs were nonphysician clinicians, including nurse practitioners, nurse midwives, and physician assistants, in urban clinics, the figure was 38.9 percent. The contingent of physicians was heavily dependent on international medical graduates and loan forgiveness programs. Even so, the vacancies for physicians totaled 428 full-time equivalents (FTEs), while those for nurses totaled 376 FTEs (Rosenblatt et al., 2006). Expansion of programs that encourage health care providers to practice primary care, especially those from underrepresented and culturally diverse backgrounds, will be needed to keep pace with the demand for community-based care. For further discussion of variation in the geographic distribution of primary care providers, see the section on expanding access to primary care in Chapter 3. viagra tadalafil diabetes certainly lilly cialis tadalafil or careprost buy online short billig tadalafil på nätet.
At the same time, the power to deliver better care—quality care that is accessible and sustainable—does not rest solely with nurses, regardless of how ably led or educated they are; it also lies with other health professionals, consumers, governments, businesses, health care institutions, professional organizations, and the insurance industry. The recommendations presented in Chapter 7 target individual policy makers; national, state, and local government leaders; payers; and health care researchers, executives, and professionals—including nurses and others—as well as larger groups such as licensing bodies, educational institutions, and philanthropic and advocacy and consumer organizations. Together, these groups have the power to transform the health care system to achieve the vision set forth at the beginning of this chapter. In conducting its work and evaluating the challenges that face the nursing profession, the committee took into account a number of considerations that informed its recommendations and the content of this report. The committee carefully considered the scope and focus of the report in light of its charge (see Box P-1 in the preface to the report), the evidence that was available, costs associated with its recommendations, and implementation issues. Overall, the committee’s recommendations are geared toward advancing the nursing profession as a whole, and are focused on actions required to best meet long-term future needs rather than needs in the short term. Compared with support for the role of nurses in improving quality and access, there is somewhat less evidence that expanding the care provided by nurses will result in cost savings to society at large while also improving outcomes and ensuring quality. However, the evidence base in favor of such a conclusion is growing. Compared with other models of prenatal care, for example, pregnant women who receive care led by certified nurse midwives are less likely to experience antenatal hospitalization, and their babies are more likely to have a shorter hospital stay (Hatem et al., 2008) (see Chapter 2 for a case study of care provided by certified nurse midwives at the Family Health and Birth Center in Washington, DC). Another study examining the impact of nurse staffing on value suggests that increasing the proportion of nursing hours provided by RNs without increasing total nursing hours was associated with 1.5 million fewer hospital days, nearly 60,000 fewer inpatient complications, and a 0.5 percent net reduction in costs (Needleman et al., 2006). Chapter 2 includes a case study of the Nurse–Family Partnership Program, in which front-line RNs make home visits to high-risk young mothers over a 2.5-year period. This program has demonstrated significant value, resulting in a net savings of $34,148 per family served. The program has also reduced pregnancy-induced hypertension by 32 percent, child abuse and neglect by 50 percent, emergency room visits by 35 percent, and language-related delays by 50 percent. how does tadalafil feel really rezept cialis-online also personally tadalafil in your 30s. Solutions to some of these challenges are well within the purview of the nursing profession, while solutions to others are not. A number of constraints affect the profession and the health care system more broadly. While legal and regulatory constraints affect scopes of practice for advanced practice registered nurses, the major cross-cutting constraints originate in limitations of available resources—both financial and human. These constraints are not new, nor are they unique to the nursing profession. The current economic landscape has magnified some of the challenges associated with these constraints while also reinforcing the need for change. To overcome these challenges, the nursing workforce needs to be well educated, team oriented, adaptable, and able to apply competencies such as those highlighted throughout this report, especially those relevant to leadership.
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