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Special Comments, The Honorable Bethany Hall-Long, Lieutenant Governor, State of Delaware
The following video features the Honorable Bethany Hall-Long, doctorally prepared nurse in health policy and nursing administration and now Lieutenant Governor of the State of Delaware. She is one of the creators of the Delaware Cancer Consortium.
Healthy Delaware. (2017, June 23). Special comments, the Honorable Bethany Hall-Long, Lieutenant Governor, State of Delaware (5:35 minutes)Links to an external site. [Video]. YouTube.
Honorable Bethany Hall-Long TranscriptLinks to an external site.
Leading Change: How Nursing Can Shape Health Care Policy
Darlene Curley: Stephen, I’ll start with you. You were an advocate for the Nurse Modernization Act here in New York. In this role, what were the biggest challenges and rewards, and why?
Stephen Ferrara: Welcome, everybody. I would say the biggest challenge… let me give a little background on the Modernization Act for those of you who don’t know what it’s about. Prior to this law taking effect, which took effect January 1st of this year, nurse practitioners in New York State needed a written collaborative agreement in order to practice. This was agreement signed by the nurse practitioner and the physician, and was required to practice, if that agreement in any way stopped existing, if the physician lost their license, if they went on and something happened bad to them, they could no longer legally collaborate with that nurse practitioner in the state, which meant that that nurse practitioner had no practice. We saw this as a big issue.
In addition, we saw that there were nurse practitioners who were paying physicians for their signature essentially. This was not the idea of the law when it was passed back in 1988. It was for collaboration and it ended up becoming more of a business transaction. We saw this as a big problem, when I say we, as part of The Nurse Practitioner Association of New York State, and as a nurse practitioner, at the time I got involved with this… I graduated in 2000 as a nurse practitioner, and really became involved in about 2006, because I saw that this was a problem, and this was when the momentum started moving forward.
Part of the challenge was that not everybody agreed on this strategy to move this forward. When we started out this bill, it was the perfect bill, it was a bill that we wanted to have as very little regulations as possible. Unfortunately, that bill sat in the legislature for about five years untouched, because there was not enough legislative support for it. At some point, we had to make the collective decision to say “Okay, what do we need to do to move this forward?” This is when we sat down, we looked at other states that had success legislatively, and we sort of came up with a bill that we were comfortable putting forward.
Now, not every nurse practitioner in New York State felt that way, some thought that we should hold out for everything, but what’s very important in New York State, and anywhere with legislation, is your window of opportunity, and being able to pass what you can pass when you can pass it. We sort of got together, made some changes that we were comfortable with, and were able to put it forward.
Of course, we had some sort of opposition within the nurse practitioner community, but we also had some opposition in the medical community as well. There weren’t many physicians who thought that nurse practitioners should be able to practice “on their own,” or independently, and although we do that when we see any patient. But I digress. There was some considerable opposition to this bill that we had to overcome, and we ultimately did. The biggest success of course is being able to sit here today and have this bill that had been passed as part of the executive budget last year, and really became law.
But, what I’m really looking forward is hearing stories about those nurse practitioners in New York State that provided access to care where there was no access prior. I think that day is to come, and I know it will come soon, and that’s what I think is most interesting.
Darlene Curley: Stephen, I think I’ll come back to you after, and ask what advice you have for nurses wanting to become more involved, as you have, and congratulations.
Stephen Ferrara: Thank you. Thank you.
Darlene Curley: To you and all the nurses in this room who worked on this legislation. Sally, you’ve been an advocate for effective health policy in the Governor’s office, and now you’re with the State Department of Health, with this experience, what do you believe to be the role of nurses, and the nursing profession in shaping health policy? How do you see this role evolving in the future?
Sally Dreslin: Thank you. Thank you for having me here. I think that the role of nursing is really to get involved in as much as you possibly can. I started out, I started out in medical anthropology, but I started out as a clinical nurse and then became an educator. I started to see systemic issues that I didn’t really know the source of those problems yet, and I didn’t know how to ask the questions. Then, when I moved on into a more advocate role, and trying to look at policy, and what was going to state, those questions became clearer. What I saw as one of the most powerful things as legislation moves at its glacial pace through the legislature, at least in New York State, and probably at the federal level as well, is hearing the nurses stories.
You can have lobbyists and you can have other folks go in and talk to legislators about why a certain bill is important, but when you bring in the nurses, and the nurses talk about what it really means to practice, what it really means to be at the bedside and the legislators start hearing those stories, it becomes real, it becomes potent, and because it’s something that they want to work for as well, so I would say, for nurses is to ask why we’re doing what we’re doing at the bedside, if you’re a bedside nurse, and if you’re in other roles, why do we do it this way? Is there another way to do it? Just get yourself involved.
You can start small, you start in your hospital. I started out on quality teams, looking at infection rates, and sort of you just move from there, but you got to take that first step and drag your friends with them, no matter how tired they are, no matter what else is going on, come on, let’s go. You get kind of addicted to it, it’s terrific to go and to see that you can make a change, and that you can have an impact on practice, and on patient care.
Darlene Curley: Thank you. What are some examples of policy discussions in your day-to-day work? How can nurses influence these discussions and lead change?
Sally Dreslin: Yeah. Today was Emergency Preparedness, in my role, I’m the Executive Deputy Commissioner, it’s sort of a strategic administrative and policy role at the Department of Health. We have a group of deputy commissioners who are over different offices, so the Office of Primary Care and Health Systems Management, the Office of Public Health, and the likes. I work with a lot of those deputy commissioners, and then of course the teams, I work with them on all of their issues. Anything from questions about how you share data, and the issues of confidentiality related to that both federal restrictions, state restrictions, local restrictions, and how do we transform our healthcare system, share data, but do it in a way that people are comfortable with, and that people feel makes their data safe.
Issues of, we just put forward the executive budget, so we’re spending a lot of time in the state, the executive budget came out on January 21st, so make sure you have a look at that, there’s lots of resources, so you can see what proposals the governor’s budget has made. We spend a lot of time briefing, so public health programs, how do we fund public health programs? How do we ensure that we’re all healthcare facilities have enough resources and are integrated with larger facilities so that they can provide the quality care that they need to provide in that patients when they need to move to tertiary care that that’s an easier transition? Medicaid policy, of course, the market place. It’s really a very broad range of topics, and I feel very fortunate and very lucky to be in this position.
Darlene Curley: We’re fortunate that she’s in this position, I’m thinking, because at that level, you are certainly an advocate for patients, and being a nurse you understand what that takes for the families and for the patients. What single national law, or regulation, would you say has had the biggest impact on nursing and patient care in the State of New York, at the bedside, and maybe in the community? And why?
Sally Dreslin: I’d like to bring that around to some of the state laws, and state regulations. I think, I mean, there’s sort of what… There’s the Nurse Practice Act, so there’s that, but other than that, I think there are some laws, and then the regulations that flow from those laws, that have impacted the nurse and care environment, that are significant. Things like Safe Patient Handling, that passed last year, to help nurses have equipment available when they’re moving patients so that they don’t get injured while they’re working. There was a ban on mandatory overtime, which was very important for both nurses and for patients, you know, overtired nurses being mandated to work, it’s dangerous for the nurse, and it’s dangerous for patients.
There was a bill that increased the penalties if someone committed act of violence against a nurse while they’re on duty, very important again, I used to be an emergency department nurse. Certainly you see that the emergency department nurses had been covered under the previous law, but the new, the amendment to that law expanded to nurses anywhere. I was also a home care nurse, and you can get into some pretty dicey situations in people’s homes.
I think there’s some broader issues that are going on in healthcare delivery system in general in New York State that maybe some of the bedside nurses, or some of the nurses who are working hard getting their degrees aren’t as familiar with, things like DSRIP, the Delivery System… Let’s see if I can get the acronym right, Delivery System Reform Incentive Payment program, which is transforming Medicaid, but that spills in to all payers, moves towards integration of services, movement of care out of the hospital into other clinical venues, and what does that mean for the workforce, changes to the way providers are paid, changes to value versus volume. Then the state health innovation plan as well, we just got a $100 million grant, a CMMI grant to again transform the way we deliver healthcare in the commercial markets.
All of it, hopefully, will align, that is our goal, I know it’s a lot of change for folks, but there is an awful lot going on that nurses should get involved in.
Darlene Curley: Thank you, Sally. I’m sure you can see that the advocacy, the local level, state and national are all intertwined, there is really no beginning or end, but it is an entry point to participate in the policy discussion, I think, that makes it a little clear. But, Stephen, what you were talking about, everything has an impact from the state and the national level on the Practice Act and advocacy. Sally, for you, get funding from the federal level, but also the regulations that affect everyone who is practicing, and every patient, whether it’s payment, or medical procedures, safety and quality, infection, all of those things where it’s all interrelated. Health policy and politics, we look at them separately, but they do come together, and we’re hearing more and more about that every day on the news.
Let’s switch over to the national level for a minute and, Sheila, ask you a few questions. What single national law or regulation would you say has had the biggest impact on what nurses do at the bedside, and why? Medicare, Medicaid, the Affordable Care Act, and what else has been a game changer in your opinion?
Sheila Burke: Thank you, Darlene, and thank you to all of you for having us here today. I can’t think of a more important topic to focus on, that is the role of nursing and really driving health policy. Clearly, at least in my view, the most critical change that has been made was the passage of Medicare. It will turn 50 this year, this summer actually, its 50th birthday. While lots of things have occurred, obviously, a lot of attention around the ACO, Medicare really began the process of driving the delivery and the financing of healthcare services in a very different way.
It was our first attempt to really step into in a very dramatic way setting quality standards, setting provider standards, setting requirements in terms of the delivery of services. As a result, it has had an enormous impact on nursing from its very beginning in terms of making provision for nursing, for nursing services, requirements for hospitals in terms of what was required, the acknowledgement of nurse practitioners in a slow, but sure and steady increase in the use of nurse practitioners in terms of delivery to services to that population of individuals.
We’ve also looked at the way we finance and recent changes to begin to look more at teams rather than at individuals, the development of things like Accountable Care Organizations, and the recent decision to essentially allow the decision making by nursing to play an enormously important role in terms of the provision of services for patients. But, it’s really, when you look back at the history of Medicare, one of the things that we forget is one, it led to the desegregation of hospitals in the South. You could not participate in the Medicare program unless you had a desegregated hospital. We forget that is one of the quiet success stories of Medicare.
We forget that the creation of The Hospice movement in part came to this country as a result of Medicare’s recognition. To Darlene’s point, we forget that there is little that we do, either in terms of how we practice, where we practice, who we care for, and who pays for us, it isn’t driven by statute, either at the federal level or at the state level. Much of that, today, is a result of the Medicare program, and the changes that it’s made.
Darlene Curley: Thank you. What policy issues do you know about that are in the pipeline, or being discussed in policy circles that could affect nurses and patients both in the hospitals and the community setting?
Sheila Burke: One of the great joys of having a career in health policy, having started as a clinical nurse in Berkeley, California, is it’s a never-ending series of opportunities. There is never a period of time when the discussions in health policy stop, or that we conclude the discussions around a lot of important issues, and today I think the ones that are critical are not unlike those that were discussed many years ago. That is the structure of the financing system, and this desire to move away from silos, and desire to move away from volume towards value. Certainly, the desire to move towards teams, and recognizing teams and the interdisciplinary nature of the way we provide services that it’s not one profession, it’s not one silo, it’s really the collective that cares for patients, the desire to take things, and I say this with some trepidation, given where I am, the desire to move people out of buildings, out of square places, and into the community, and to really allow people the choice about where they want to be cared for, and by whom.
All of those are really coming to the forefront in terms of the discussions around payment reform, moving towards bundling of payment, so that we look at the full continuum of care. The desire to look at the pre-admission, and post acute, and essentially have those transfers take place, and how we assure quality across those settings. Also, the whole question of transparency, and that is how do we engage the patient in helping to make the decisions? What kind of information informs them, allows them they become a full participant? How do we engage in terms of family members rather than simply keeping that behind some wall of professional knowledge, but really sharing with people the kinds of decisions that they need to make in terms of their care.
Recently, a lot of attention to dementia, to long term care services, it’s something we’ve successfully avoided talking about for years, but the sheer demographics that we’re facing today, the oldest population, those over the age of 85, are the fastest growing age cohort. Suddenly, we are faced with a silver tsunami in terms of the population that we have to care for. A lot of attention is being given to where they best care for, by whom, and under what circumstances. Really, there are lots of opportunities for nursing to essentially get involved.
This idea that public health is a new form for nursing forgets our history, and that we were the first ones in the home, we were the first ones in the community, and that opportunity, I think, has arisen once again.
Darlene Curley: You mentioned financing, and sometimes that’s the first place where we notice that something has changed, a budget document, whether Sally, you were talking about the state, and then the federal budget is out, and there’ll be a lot of implications for nursing, and for patient care, but the budget document is the policy document of whoever the governor is, or the president putting that out. Someone can say “I really care about patients with dementia,” but when you look at the budget, funding may have been cut. For all of us, it’s a good way for us to really see what someone’s priorities are, and you both, you know this very well from your experience.
Sheila, in the last congress, there were 20 physicians, and five nurses, how do you think having people with a clinical background in nursing and medicine impacts the national debate on health policy?
Sheila Burke: Let me tell you just very briefly, a brief story. When I first went to work for Bob Dole, I was someone who was born and raised in San Francisco, trained in California, practice in Berkeley, was a practicing liberal democrat, and my idea of rural was Oakland. I went to work for this remarkable person who wasn’t concerned about my politics, but cared that I’d cared for patients. He really wanted someone to handle health policy, who’d actually been in a patient care setting. But, recognizing who I was, and where I was from, his first suggestion to me was “If you have a question about healthcare and about rural healthcare, and what takes place in the bulk of the country, not on the coast, I want you to call [Art Glenn 00: 19: 43].” Art Glenn was his mother’s optometrist in Russell, Kansas.
Now, I tell you this story because the impact of people who’ve actually provided services, who have a keen understanding of the delivery system, how the translation between what the policymakers do and what the practitioners practice, there is a gulf as wide as the Grand Canyon in terms of the implications for the changes they make in how you practice every day. The presence of physicians and nurses in those positions, the presence of nurses and physicians, and other healthcare providers, in state legislatures, in local and county government, are enormously important. Of course, we have a history of two nurses so far who’ve run essentially the agency that runs Medicare, Medicaid, Carolyn Davis, and Marilyn Tavenner, both nurses, both of whom led that enormous agency, have the opportunity of helping to translate what the policymakers think they’re doing into what the practitioners actually confront.
I think the presence and active membership of members is enormously important, as is the involvement of folks that are in the community, in helping people translate what’s taking place.
Darlene Curley: Thank you, Sheila. Sally, what about you, you’re our nurse in the Health Department in New York—
Sally Dreslin: [crosstalk 00: 21: 09].
Darlene Curley: What about people that are elected to office too, are they advocates for you? Are you able to work with them in a different way, physicians or nurses, that serve New York State?
Sally Dreslin: Yeah. I completely agree with what you’re saying about the presence, there are, I think, there are two nurses currently, there’s one nurse in the Senate, I believe, and one nurse in the Assembly. There are some physicians, some pharmacists in the state legislature, and I think it does, it brings tremendous depth and dimension to the policymaking, and it helps to actually have some more constructive conversations about the proposed policies, and the proposed changes in the budgets, rather than just knee-jerk rhetoric, you can actually get into “well, you know, I’m a pharmacist in my full-time job, and I understand what you’re trying to do, but this is what it’s going to do in practicality, maybe we can talk about it.” It kind of lends some rationality, I feel.
Darlene Curley: That’s what nurses can do, is sort of walk the dog to the end of the road, right? Take the policy and say “That’s fine, but what does that mean at the bedside and the community to my patients, to my practice? What does that mean?” Then, provide feedback to those in government about “This doesn’t work, it sounds like a really good idea, but it doesn’t really work because of thus and so, or maybe there’s a better way to do it. Can we work together and find a better way?” Stephen, what suggestions do you have for anyone here who wants to be more involved in policy work?
Stephen Ferrara: I think what’s really important is to know the issues, and really study them very well. One of the biggest questions I still get asked in my role is, there’s still a confusion between state policy versus federal policy, and what could be done in the state versus what cannot be done in the state. I think it’s really, really important to read up on the issues, we’re all passionate about something, a lot of us here, at Columbia, make this sort of your life work, that’s what I’ve been so impressed with. You’re doing already, and you want to really, really study up on it, that’s number one, then number two is, it comes down to sometimes money, it’s become familiar with an organization that is like-minded as you, look at what they’ve been doing, do they have a PAC? Which is a Political Action Committee. Those PAC funds are what gets the invites for the staff members to go to a lunching or a breakfast, and speak one-on-one with a legislature, a lawmaker.
Those are really, really important initiatives that you can do. It’s also grassroots. You’re a nurse, you work with nurses, is your co-worker just as passionate about this issue as you? If not, why aren’t they? You need to build sort of an army, if you will, of people who are willing to go to [inaudible 00: 24: 21], or are willing to take the time to go to the capitol, or go to Albany, or go wherever it is that the lawmakers need to see you, they need to see the providers in all of this. One of the things I wanted to mention also is that, and I just mentioned this in one of my recent lectures, is that nurses make up the largest part of the healthcare workforce, that’s not debatable. But, we’re very well underrepresented when it comes to congress and the legislature.
What boggles my mind is that Gallup poll comes out every year, every year nurses are at the top as the most ethical, and honest profession out there, it’s been 14 years in a row, except for 2001, when it was firefighters after 9/11. But, it’s the truth. We need to leverage to this power, we need to be visible, and I think it’s volunteering, it’s getting out in front of the issues and becoming part of either your state association, or your national association.
Darlene Curley: This has been a great discussion, I’d like to ask each of the panelists to just make a closing comment based on what sort of we’ve heard today, any kind of thing you want to do to tie up, and then also everyone will be available after for any individual questions. [inaudible 00: 25: 48] would like to start.
Sally Dreslin: Stephen.
Darlene Curley: Stephen. Your panelist assigned you to the first [inaudible 00: 25: 57].
Stephen Ferrara: That’s why I sat in this seat. I think there is tremendous power of our profession, and I think it’s time that, not a call to action, but here we are, we obviously have a major impact in the healthcare system, and one of the things that I was sitting here reflecting on is when you mentioned that Medicare started in 1965, which is when the Nurse Practitioner movement really started too. It sort of Medicare happened even before the profession of nurse practitioners were born. As a result, we’re seeing that there is opportunities for nurse practitioner inclusion that necessarily wasn’t written at the time when Medicare laws were.
I see it as lots and lots of opportunities, and there’s lots and lots of work to do. It may sound cliché, but if you’re in healthcare today, and you’re not accustomed to change, it’s going to be a bumpy ride, because it is changing right in front of our eyes, healthcare systems are changing and when we’re looking at just changing things from outcome space rather than volume-based, it is profound, it’s… Medicare just announced that by 2018, that 50% of those payments from Medicare should be quality-driven metrics. I see 30 patients, I’m getting paid for 30 patients, those days are going, we need to be ahead of that curve, and I think we are. I think it’s forums like this being able to acknowledge the issues, and sort of set a path to make that change. Stay strong and continue.
Darlene Curley: Thanks, Stephen. Sally?
Sally Dreslin: I think I would say sort of accept the fact that you can have an impact. Don’t feel like you have to have gotten from A to B in a straight line. I worked in a lot of different clinical settings, I moved around, and I never, when I started nursing, when I graduated from the ETP program in 94, would have never in a million years imagined myself in the situation that I’m in now. But I will tell you that everything I did along the way, including what I did before nursing, has made me better at what I do now. Just let it happen, but have the confidence to know that you can make a difference, and that what you see and what you think might be another way to do it is valuable.
Darlene Curley: Thank you.
Sheila Burke: I think that each of my colleagues has, I think, suggested the kinds of things that should drive us to become active participants. Certainly, we all go through interesting and circuitous careers, I certainly did. But, at the heart of it is the fact that we’re all educated as nurses. We bring with us a sense of the importance of the role that we play. It’s interesting that those skills that we acquired in terms of interpreting very complicated data, in working in teams, all the things that were at the heart of our education, are applicable to these broader challenges that we’re now facing.
Although, I have to note at one point, when I ran the Smithsonian, we were losing a lot of animals at the zoo, the Smithsonian in Washington runs the zoo, and I suggested to the zoo director the next thing that died better be her, which was probably not exactly in keeping with my training. But, in fact, remembering what it is you bring to the table. I’ve had so many people say “Well, I don’t really have anything to contribute. I don’t really understand policy. I don’t really understand the sort of discussions.” You are uniquely equipped to engage in those conversations. There isn’t a conversation about healthcare in which nurses don’t play a role, and that you don’t play a role. Don’t ever be hesitant to raise your hand, identify yourself as a nurse, and become engaged in those conversations, whether it’s at the local level, or the state level, or at the federal level.
But, at the heart of all of this, remember that we are blessed in this country with the ability to vote, and it really does make a difference. A sense that it doesn’t matter is a disconnect from the truth. It really does matter. If you’d learned nothing else from this process, it’s that you have to vote. I don’t care if it’s blue, or red, or whatever other colors are available at the time, green, but voting is an important part of your personal responsibility as a healthcare provider to make sure the policies that are being driven are ones that’ll support your patients.
Darlene Curley: Thank you. We’re going to have one short special presentation to conclude our program. Stephen.
Stephen Ferrara: The other thing I would say is, you definitely want to take advantage of your connections. For the Nurse Practitioner Association, when Sally was in her role with the Governor’s office, she fought very, very hard for nurse practitioners, and this was a plaque that we had intended on giving to her at our annual conference in October, but then Ebola broke out. We didn’t have the opportunity to present it to her. On behalf of The Nurse Practitioner Association, I present Sally with this plaque. You’re welcome.
