The Rising Cachet of Nurses

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I’ve been thinking a lot about nurses lately. Here’s what I’m thinking.

Why now?

Nurses are in shortage while being in demand, they are needed for more individualized patient care, and they are becoming greater revenue drivers instead of cost centers.

The market is changing, and nurses should know their value. Some of my reasons are contrarian, perhaps. But I think I’m on the right track.

Nursing Shortages are Worsening

Isn’t this a BAD thing?

Well, yes, for the rest of us who need nurses. It may get worse before it gets better.

But nurses are in short supply, which creates demand and more room to negotiate. If I were applying for a new clinical role like a nursing position, here are some things I’d try to negotiate:

• A higher starting salary (the obvious)

• Paid leadership training programs

• More PTO

• Paid graduate education

• Paid-off school loans

• A specific percent raise after one year if goals are achieved

• Flexibility in scheduling

• A chance to share innovative ideas at cross-functional team meetings

• Quarterly exploratory meetings with skip-level leaders to identify problems (so you can think of creative solutions)

• A growth and development plan with your manager

• A chance to serve on committees

• A chance to participate in research

Clinicians of all kinds, also keep this in mind:

If you want to pivot your career, move into leadership, or growth is a goal but you don’t know where you want to go yet—the easiest place to grow is often in a lateral, non-clinical role where you are already working. But if you are working for an employer who won’t support your growth, it may be necessary to consider a different one. (*This is not advice to any reader.*)

Let’s explore a few dynamics creating a growing demand for nurses and a higher value being put on the profession overall.

The Nursing Home Staffing Mandate will Have a Ripple Effect

Some of the most vulnerable members of society live in nursing homes. Regulations set standards and expectations for the sector. The Biden Administration has been actively pursing higher levels of oversight on nursing homes after the COVID pandemic exposed gaps in care and patient safety in this sector of the healthcare continuum.

Right now, nursing homes must provide at least one nurse per building for a total of only eight hours per day. They have to provide licensed staff 24 hours per day. President Biden committed to changing this in February of 2022. In the time since then, the final rule was published, calling for an even higher nursing oversight level that originally proposed. 👇️ 

This may not be the actual final word on the staffing mandate, expected to go into effect on a rolling basis, with rural communities last to have to comply. As you can imagine, the American Health Care Association (AHCA) is not happy with the mandate. They are suing the federal government for CMS acting outside their statutory authority to mandate a minimum staffing rule. The overturning of the Chevron deference has AHCA feeling more confident they will win in court.

Assuming staffing requirements do lead to more RNs needed in nursing homes as part of their conditions of participation, it is likely those nurses will command higher salaries.

I like the perspective shared in this article in Skilled Nursing News. It suggests that as dynamics shift that require SNFs to function more like hospitals for short-term stays, nurses will get to the point where “it will be offensive for SNFs to send residents to the hospital.” The article also provides data about the lower wages in SNFs compared to acute care hospitals (ACH).

This will also have an impact on resources for home-based care providers.

As more home-based care provider types fill the landscape (such as those needed for hospital-at-home), more nurses will need to be recruited to the home setting. Certified home health agencies are also likely to grow in their part of the post-acute pie when models like TEAM and AHEAD incentivize hospitals to reduce care continuum spending (such as in SNFs).

Advanced Primary Care

Advanced primary care success depends on teams of healthcare professionals working at the top of their license to provide valuable, individualized support to their patients. In the most mature practices, often where the providers have been delegated full financial risk for their patients, we see the most innovative problem-solving happening.

I love that the aligned incentives are allowing these practices to make patient care management make more sense.

A classic example of how nurses are using their skills in this setting is patient appointments made directly with the nurse.

In full-risk practices paid a prospective, monthly payment with future shared savings opportunities, CPT billing codes aren’t the driver of reimbursement, so they aren’t the driver of operating practices. Giving patients what they need to manage their health and remain home and in the community becomes the guiding light.

Individuals with chronic conditions often need help and support to learn to manage their health. The nurse will work with a diabetic on managing their blood sugar and providing ongoing diabetes educational support, for example. They will see a patient with congestive heart failure regularly to counsel them on diet, medication management, and more, and to identify concerns of exacerbation that should be escalated to the practice’s physicians or advance practice providers.

Nurses serve a critical role in supporting the prevention of disease exacerbations for the practice’s patients. They have important value in reducing total cost of care across the continuum. Where we have seen practices consist of physicians, advance practice providers, medical assistants, and office staff, we now see practices recruiting for nurses to build out their clinical teams.

Care Management Roles

Part of the work of RNs in advanced primary care is to provide care management services. This includes chronic care management, transitional care management, complex care management, and more. But it’s not just in advanced primary care.

CMS has created an on-ramp to advanced primary care over the past decade, building additional codes and services to account for the work primary care practices would be doing if there were billing codes for it.

For practices even just getting their feet wet before moving into something like the Medicare Shared Savings Plan (MSSP), practices can add an RN to their team to provide and bill for care management and related services for patients who qualify and would benefit from these services.

Some fondly call codes like chronic care management “good codes” in fee-for-service. They do add to total cost of care on the front-end, but they can reduce avoidable emergency and acute care, engage patients in their health and care to slow disease progression, and build and strengthen the trust between the patient and practice on the back end.

We actually need more volume of the right primary care services at the right time if we even hope to improve the health of the population and reduce the cost of caring for them. See the complete list of Medicare Preventive Services as of 8.20.24 👇️ 

One way to prepare for participation in risk-based alternative payment models and progression to advanced primary care is to hire a nurse with experience in care management and begin providing upstream services to patients with chronic conditions.

These nurses can also assist in annual wellness visits, completing a large portion of it before the provider sees the patient. Annual wellness visits are also crucial to success in value-based care for any payer, so pre-VBC contract is a great time to get experience doing them. In addition, the nurse can complete the Social Determinant of Health Risk Assessment and begin discussion of Advance Care Planning during the nurse-led portion of the Annual Wellness Visit.