SCITUATE – All paths for the future of the delivery of patient-centric health care in Rhode Island will pass through the nexus of the nursing profession, which is the midst of a major transformation.

There is a push – part of a national agenda by the Robert Woods Johnson Foundation – to have nurses receive a bachelor’s degree and not just an associate’s degree.

The changing role of nurses within the patient-centered medical home model for delivery of primary care has led the R.I. Chronic Care Sustainability Initiative to explore the potential development of a new graduate certificate program for nurses, working in partnership with Rhode Island College.

The proposed rehab of the Dynamo building in the heart of the Knowledge District has, as one its central redesign plans, a collaborative nursing education facility, supported by Brown University, the University of Rhode Island and Rhode Island College, among others.

In addition, a Rhode Island Nurse Residency Program has been launched for unemployed and underemployed nurses, as part of a partnership between labor and management.

Lynn P. Blanchette, R.N., is very much at the center of this vortex. She is the director of the B.S. nursing degree program at Rhode Island College, which has seen a dramatic increase in applicants.

“We’re swamped,” Blanchette said. “We admit 75 students each semester, spring and fall, and we have had to turn away 10 to 15 percent of the applicants because we can’t accommodate them. We don’t have the number of faculty or the resources in order to educate more nurses,” she said, not at Rhode Island College nor at the University of Rhode Island.

Blanchette praised the work being done by the R.I. Nurses Institute Middle College Charter High School in preparing high school students for a nursing career. “A really important piece of that school is the access it provides to students from diverse communities,” she said. “As in our school, in our profession, diverse communities are under-represented. We don’t look like the community.”

Blanchette is also one of the leaders of the Scituate Health Alliance, which provides primary health care services to low- and moderate-income Scituate residents who have no health insurance or health insurance that does not cover primary health and dental care. The only cost to the patient is $10 per visit.

The work is funded through a community block grant and with the help of foundation grants, according to Blanchette, with a focus on maintaining good community health through access to primary care – including flu clinics, health screenings, access to vision care, baby and breast-feeding education, even home fire safety.

Every semester, as part of the community health curriculum, Blanchette leads a clinical group of nursing students to do outreach work as part of the Scituate Health Alliance.

Transition and transformation
The transition to the patient-centered medical home has not been easy, as it has meant disrupting patterns of established behavior for doctors, nurses and patients. The reality is that there are now about 200,000 Rhode Islanders who are being seen in PCMHs for their primary care under the R.I. Chronic Care Sustainability Initiative, or CSI-RI. That number is planned to grow to 500,000 in the next three years. If the State Health Innovation Plan is funded by the Centers for Medicare and Medicaid Service, as many as 80 percent of Rhode Islanders – some 800,000 – would have their primary care delivered through a PCMH.

“Nursing in Rhode Island is very much coming together to think about the future profession in this state,” Blanchette said, pointing the Rhode Island Action Coalition, a partnership of more than 20 organizations.

One of the biggest changes is the switch to community-based health care and the reduction in the number of acute care beds at hospitals, Blanchette continued.

A work in progress is a nascent collaboration with CSI-RI and Rhode Island College to think through what a new certificate of nursing for patient-centered medical homes would involve.

Faculty from nursing programs across the state were invited to attend a CSI-RI management meeting to think through what was going to needed in the future – what kinds of special skills would be important to have, according to Blanchette.

As a result, a new certificate program at RIC as part of the graduate program is under consideration to match the skills needed with what is emerging as a brand new model of nursing care.

Moving beyond theory into practice
Blanchette said that the patient-centered medical home was a fabulous idea that worked very well in a small laboratory with a specific group of nurses with a core set of skills, but when it gets rolled out, like anything else, there will be some bumps in the road.

“It’s very difficult to got into a practice, one where they’ve been doing the same things for 10, 20 or 30 years, and expect that the changes will go smoothly,” she said, responding to a question about negative feedback from the new model of care.

“Patients are being asked to change their behaviors; that’s not really an easy thing to do,” Blanchette said.

To work, the patient-centered medical home model has to be about more than just saving money, Blanchette continued. It has to be about improving health outcomes, where people become healthier than they were before.

Moving forward
Blanchette, who is a strong advocate of the neighborhood health station idea that is part of the Dr. Michael Fine’s proposed Primary Care Trust, also believes that the state needs to invest more money in the R.I. Department of Health’s public health programs to enable nurses to be working in conjunction with communities in evidence-based programs.

The state budget has been restricted in recent years, she continued, with the effect of severely limiting and curtailing programs. “I started as a nurse in community health more than 30 years ago. That money has dried up and needs to come back,” Blanchette said.

Blanchette also believes that the state could make better use of its limited resources by investing in the four-year B.S. programs for nursing and limiting funding for two-year programs for associate degree levels. “We need to take a look at resources allocated to the Community College of Rhode Island to see if there is a better fit in one of the baccalaureate programs,” Blanchette said.

“Change is not easy,” she said. “It takes patience and perseverance and a sense of curiosity about what can you do to make things work really well.”