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I will begin by answering question number 2 related to priorities in health and health care from the National Academy of Medicine (NAM) (Rowe et al., 2017). There were a few priorities that piqued my interest, but I selected priority four, better health and health care for an aging population, a topic I am passionate about. I have recently experienced the decline and ultimate death of both of my aging parents and this priority has been in my face. My father needed an advocate to coordinate his care and I filled that role, flying to Milwaukee for at least a week every two months to take him to medical appointments and generally more often emergently to spring him from an unexpected hospital visit. My father lived in a large assisted living facility with many levels of care. I not only got to know most of the residents, but experienced the issues with understaffing, inadequate training, and turnover of direct care personnel as discussed in the paper (Rowe et al., 2017). In Wisconsin, there is no requirement for certification or specific training for unlicensed assistive personnel in these care facilities. While many were quite excellent, others were not. Additionally, my DNP project relates to transitional care of traditional Medicare recipients discharged from hospital to home and the developer of the evidence-based model I used for my project was one of the two nursing authors of this paper.

The NAM identified this priority due to the aging population and the increased risk of frailty and disability as well as isolation and chronic illness among this population. Health care expenditures in this age group are five times more than for children and three times greater than younger adults (Centers for Medicare and Medicaid Services, 2016), and the largest expenditure is often in the last few months of life.

The NAM identifies several strategies to accomplish this health priority. New models of health care delivery are needed (Rowe et al., 2017). One such model was being piloted at my father’s care facility by Optum Health, a branch of United Health Care. I enrolled my father in the program and was impressed with the benefits. In the Optum Assisted Living Plan, a nurse practitioner was in the facility three days each week and one was on call 24/7. They were the first-line care manager for plan participants. If my dad seemed sick, my sister didn’t have to take a day off work to take him to the urgent care. Instead, he could be seen and treated by the nurse practitioner who would then call me. If he needed a higher level of care, he could be moved within the same facility to the sub-acute care unit instead of going to the hospital. This is certainly a win-win for my father and the insurance company. The hospital is the worst place for a 91 year old! This program was spearheaded and implemented by APRNs, so certainly was influenced by nurses.

Another recommendation is to increase the geriatric work force. Providers specializing in geriatrics are in short supply and more will be needed. Again, this is a niche for nurse practitioners. Even family nurse practitioners have a scope of practice throughout the lifespan and could develop their expertise in geriatrics. I have become better educated just through my experiences over the past two years.

Support of social engagement of older adults was also recommended. In the facility where my father resided, there was a whole department responsible for keeping the residents busy and activities abounded. I do envision a disparity in this area. My father had long-term care insurance that paid for his very expensive elder care. Less affluent individuals likely lack resources to choose “good” care facilities. I did discover that once seniors have exhausted their resources, they are generally eligible for Medicaid who will pay for long-term care to some extent.

Finally, better end-of-life care is recommended. About three weeks before my father’s death, he had some type of neurological event that made it impossible for him to ambulate, even with his walker, and unable to swallow. This is a man who skied in the Rockys until age 85 and rapidly lost first his wife of 67 years, followed by his ability to drive and gradually his mobility and continence of urine by age 91 due to a progressive incurable disease; vascular dementia. His hospitalist wanted to tube feed him. Even though my father had a living will and was cognizant enough to tell me he did not want tube feedings, and even though I am well-versed in end-of-life ethics, watching my father die was the hardest thing I have ever done. Hospice, good mouth care, sips of thickened “pleasure drinks”, and my father’s enduring sense of humor kept it tolerable. I can imagine many families who lack a knowledgeable advocate being completely unable to manage such a situation.

Nursing is in a perfect position to participate in improving all aspects of health and health care for our aging population.

Student B:
1. Review Figure 1-4 in Mason et al., 2016, p.10 regarding the forces that shape health policy—consider the impact of these forces on the policy process. Propose, or report on actual events, nursing involvement in each area at the national, state or local level on some policy. If you can find a policy that illustrates all of the forces, great. If not, use examples from two or more policies to illustrate the way nursing has, or could have, harnessed these forces to bring about policy change.

We all agree that nurses should be involved in policy making. According to Mason et al. (2016), “As the largest health care profession, nursing has great potential power,” (p. 4). I will use the example given in the reading about patients that needed workman’s comp paperwork completed in a rural area where access to a physician was limited. The practice act for nurse practitioners was changed to allow them to complete this paperwork. This improved patient access to care. The problem was identified and then the nursing organization in the area was able to lobby for change. I will give of examples of how each force could have theoretically been involved in the process.

Values—The policy makers decided that individual access to care was important to public health

Politics—A State congress woman may have decided that delayed workman’s comp evaluations are negatively impacting the economy.

Policy analysis and analysis—The stakeholders involved probably analyzed the “causes of the problems, identified ways a government or other groups could respond, evaluated alternatives, and determine the most desirable policy choice,” (Mason et al., 2016, p. 10).

Advocacy and activism—Individual nurses could have alerted the states nursing organization.

Interest groups and lobbyists—The state nursing organization would be the interest group or lobbyist.

The media—The local news stations could alert the public of the problem and encourage people to attend the public meetings on the subject.

Science and research—Evidence that nurse practitioners provide the same quality of care could be brought to the table.

Presidential power-The Governor for the state could sign an executive order if a bill was unlikely to be passed through the state legislature.

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