DiversityNursing Blog

By Marijke Durning

AN INTRODUCTION TO NURSING CAREERS

By LAURA GEGGEL

For health care workers and researchers, wearing pressurized, full-body suits around Ebola patients may be counterproductive to treating the disease, say three Spanish researchers in a new letter published in the journal The Lancet. But other health experts, wary of wearing less protective gear, disagree.

Health agencies often require that health care workers caring for Ebola patients wear hazardous material (hazmat) suits that protect against airborne diseases. But the Ebola virus rarely spreads through the air, according to the researchers at the University of Valencia and Hospital La Paz-Carlos III, in Madrid.

Ebola is transmitted through contact with infected patients' secretions (such as blood, vomit or feces), and such contact can be prevented by wearing gloves and masks, the researchers wrote.

Wearing full-body protection gear is "expensive, uncomfortable, and unaffordable for countries that are the most affected," they said. It may also send the message that such protection against the virus is being preferentially given to health care workers and is out of reach to the general public, they wrote in their article. [Ebola Virus: 5 Things You Should Know].

Moreover, the image of health care workers in hazmat suits could lead to panic, causing people to flee the area and possibly spread the virus elsewhere, they added.

Instead, protective gear such as gloves, waterproof smocks, goggles, masks and isolated rooms may be enough to manage infected patients, so long as they are not hemorrhaging or vomiting, the letter said. "In control of infectious diseases, more is not necessarily better and, very often, the simplest answer is the best," the researchers wrote.

The current Ebola virus outbreak is the worst in history. It began in February 2014 in Guinea and has since infected people in Liberia, Nigeria and Sierra Leone, killing more than 1,500 people. Just 47 percent of infected patients have survived.

But other experts disagree with the researchers, saying a high level of protection against the virus is needed in places with struggling health care systems, including the countries in West Africa where the outbreak is raging.

"The authors have a point, but I don't think a very strong one," said Dr. William Schaffner, a professor of preventive medicine and an infectious disease specialist at Vanderbilt University Medical Center in Nashville, Tennessee, who was not involved with the letter.

"It must indeed be unsettling for people to see folks in hazmat suits come into their communities," Schaffner told Live Science. "It's very foreign, and often increases their anxiety about events."

But it's better to err on the side of safety, he said. Because the Ebola virus does spread through contact with infected bodily fluids, if health care workers don't immediately clean up such excretions, it's possible these fluids could infect others not wearing appropriate protective gear.

Patients may also start vomiting or bleeding at any time, increasing the risk of infection for health care workers who are not wearing protective suits, he said.

"I would remind us that there are any number of health care workers, including Dr. [Kent] Brantly and Ms. [Nancy] Writebol, were using elaborate equipment in Africa and nonetheless became infected," Schaffner said. (Brantly and Writebol have both since recovered.)

In hospitals with cutting-edge technologies, such as Emory University Hospital, health care workers may not have to wear full-body suits for all Ebola patients, if the patients are on the mend, he said. If they are not displaying symptoms such as vomiting or bleeding, health care workers may be able to scale down their uniforms and use goggles and gloves in lieu of wearing hazmat suits, Schaffner said.

But "when you have a circumstance as hazardous as Ebola, it's important to be secure," Schaffner said.

Source: http://www.cbsnews.com

By Caitlin Schmidt

When you're sick, sometimes it feels impossible to get out of bed, let alone get to the doctor. And the last thing anyone wants to do is spend hours at the emergency room.

So Silicon Valley is retooling a service that was common almost a century ago: the house call. Several companies have developed smartphone apps that bring doctors to patients, often in less time than it would take to seek treatment elsewhere. With apps like Pager and Medicast, a patient can request a doctor with the push of a button.

In the 1930s, physician house calls accounted for 40% of medical visits, according to a 2011 article in the journal American Academy of Family Physicians. By the 1980s, that number had dropped to 1%, due in part to a lack of funding by insurance carriers.

Elizabeth Krusic, a mother of two young children from Seal Beach, California, knows how difficult it can be to take a sick child to see a doctor. When her daughter developed an eye infection, she took a friend's advice and tried Medicast, calling a doctor into her home and saving the stress of getting her small children ready and out of the house.

The doctor arrived in 30 minutes and had the necessary prescription medication on hand.

"My son was able to sleep during the entire visit, because the doctor came to the house," Krusic said. "The doctor came into my daughter's room and conducted the visit there, where she was comfortable."

The house call also removed the risk that her children would be exposed to illnesses in a waiting room.

Inspired by Uber

In early 2014, Uber co-founder Oscar Salazar saw room for improvement in the health care system and seized the opportunity.

The app he developed, Pager, offers house call services for customers in Manhattan and, starting next week, Brooklyn. Pager's doctors are available from 8 a.m. to 10 p.m., 365 days a year, with an additional after-hour fee for nights and weekends.

Toby Hervey, Pager's head of marketing and business development, said that several aspects of Uber informed Pager's approach. Like Uber, the app is structured as a mobile, location-based service.

"Convenient access to quality health care when you need it is a real problem," he said. "We're using technology to make the house call -- one of the best ways to get personal care -- viable again."

Hervey said customers range from parents not wanting to take a sick child to an emergency room to businesspeople with no time to see a doctor during the day.

A similar company, Medicast, started in South Florida in late 2013, with services now also available in San Diego, Orange County and Los Angeles.

"Long wait times are frustrating for everyone," Sam Zebarjadi, co-founder and CEO of Medicast, said. "With the proliferation of technology and increasing levels of education, we knew there were alternate ways to get amazing health care."

Dr. Kimberly Henderson is a Pager physician and works in the emergency room at New York's Beth Israel Medical Center. For her, the idea of being a part of a new practice of medicine was appealing.

"I believe we will see a shift away from medical practice exclusively in the brick and mortar model," Henderson said. "Medicine will become, or return to being, more mobile."

As the doctor shortage grows and patients struggle to balance their busy lives, telemedicine has become a fast-growing field. Health care professionals offer their services using two-way video, e-mail, smartphones and other forms of technology. Apps, such as Doctor on Demand and Ringadoc, allow patients to speak to a physician via phone or video chat.

Doctors enrolled with the service PINGMD can receive text, photo or video messages from their patients that can be forwarded to colleagues for referrals and are automatically saved to the patient's medical file. Another app, HealthTap, connects patients to 50,000 doctors across the country for verified answers to medical questions. Patients can search the database or ask their own questions and receive responses from multiple doctors, providing them with several opinions.

The American Medical Association says that telemedicine, including house call services, is useful for both patients and the health care industry as a whole, according to its June Report on the Council of Medical Service.

"Telemedicine, a key innovation in support of health care delivery reform, is being used in initiatives to improve access to care, care coordination and quality, as well as reduce the rate of growth in health care spending."

How house call apps work

After a brief video conference, a doctor will assess the patient's need for a home visit. If no visit is necessary or the physician recommends a trip to the emergency room, there's no charge.

"With this system, we're able to provide high quality care that goes beyond the issue at hand," Zebarjadi said. "With the doctor visiting patients in their own homes, it's easy to make observations and discuss other health concerns and lifestyle choices."

"I love the concept of bringing our services to people's homes," said Medicast's Dr. Elisa Malin. "It's a convenience factor, both for the patients and for us as physicians, in the sense that I can choose to be on call whenever I'm available."

Malin also works as a pediatric hospitalist for Kaiser Permanente. She said that a typical house call visit lasts about 45 minutes, as opposed to the average 10-minute visit at a clinic.

"The fact that I get the luxury of time with Medicast patients improves the quality of care they receive."

With both apps, physicians follow up with the patient via phone and are available to answer any questions that may have come up since the visit.

Although the apps are only currently available for iPhone, Pager and Medicast are actively working on an Android app. For non-iPhone users, their services are also available by phone and on their websites. They also have plans to move into other markets in the near future.

The house calls are comparable to an urgent care visit, and cost much less than the emergency room, where many people still go to seek treatment for minor ailments. Both companies offer flat rates, starting at $199 for a house call. Customers can also sign up for a monthly plan that allows them two or four visits a year.

The companies aren't able to accept insurance, but are in talks with various providers to make that option available in the future.

House calls have their advantages, such as privacy and convenience, according to Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons. They also can save on office overhead for physicians. But they do have limitations, she said.

"The doctor's black bag won't have all the equipment available in the office," she said.

Both companies' websites have long lists of conditions they treat, such as cold and flu, sprains, eye infections, pneumonia, abdominal pain and cuts that require stitches. But there are also conditions their doctors cannot handle. You should call 911 or go to the emergency room if you are experiencing chest pain, shortness of breath, or have had a head injury and lost consciousness.

Source: www.cnn.com

Source: www.rntobsnonlineprogram.com

By Teresia Odessey of Bloomfield College

As a nursing student, I have had the privilege of observing many nurses in different units; pediatrics, maternity, the burn unit, hospice, medical surgical, ICU, CCU, wound rounds, and psychiatry. I’ve realized from these experiences that school nurses are by far the most unappreciated and de-valued. As I gathered information on the role of school nurses, and shadowed an elementary school nurse for my senior capstone project, I discovered the challenges faced by school nurses. 

Contrary to popular belief, the school nurse’s role is critical to the well-being of students’ health and academic achievements. The scope of practice for the school nurse includes supervision of school health policies and procedures; promotion of health education; health services; competence of interventions; facilitation of health care screenings; making referrals to other healthcare providers; patient advocacy and maintenance of the appropriate environment to promote health. This role requires the nurse to be knowledgeable and competent in various skills and interventions. School nurses provide care, support and teaching for diabetes, asthma, allergies, seizures, obesity, mental health, and immunizations to all students (Beshears & Ermer, 2013).  The role of the school nurse as defined by the National Association of School Nurses is as follows: “a specialized practice of professional nursing that advances the well-being, academic success and lifelong achievement and health of students” (Board, Bushmiaer, Davis-Alldritt, Fekaris, Morgitan, Murphy &Yow, 2011). 

Clearly, it is not just about Band-Aids and ice packs but still 25% of US schools have no nurse present and 16% of students have a medical condition that warrants a skilled professional (Taliaferro, 2008).  One in every 400 children under 20 years is diagnosed with diabetes; 10% of students nationwide have asthma; prevalence of school allergies have increased drastically; 45,000 students are diagnosed with seizures each year; obesity rate has tripled among children 6 to 11 years, and more than tripled for children 12 to 19; and one in five students have mental health issues (Beshears & Ermer, 2013).  

Despite having laws allowing disabled children to attend school, increasing the workload on the nurses, there are no laws that mandate a nurse to student ratio. The national recommendation for nurse to student ratio is 1:750 but on average some nurses are responsible for up to 4,000 students (Resha, 2010). Nwabuzor (2007) mentioned that parents and stakeholders cannot truly advocate for more school nurses because most of them do not comprehend the role, responsibilities, and advantages of having a school nurse. The major reason for the school nurse shortage is the lack of legislation on school nursing; not enough funding, and no laws forcing schools to hire nurses. Therefore, many educational facilities have opted to hire unlicensed assistive personnel (UAP) instead. 

 Yes, it is likely more cost effective to hire UAP’s instead of Registered Nurses but that does not make it acceptable. It is my belief that we have different titles and scopes of practice for a reason. I find it mind boggling that some schools do not have school nurses. How is it that some parents are comfortable with sending their children to a school without a nurse? Is it that they don’t inquire about the presence of a school nurse? Or could it be that maybe they assume that every school has a full-time nurse? I wonder if some parents are aware of the nurse to student ratio at their child’s school. Yes, there are budget cuts due to many reasons but why do these schools say they don’t have enough funding to hire a school nurse but they have six assistant coaches for any one of the sports? So yet my question remains unanswered: what is the priority?

References

Beshears, V., & Ermer, P. (2013). SCHOOL NURSING: It's Not What You Think!. Arkansas

Nursing News, 9(2), 14-18. 

Board, C., Bushmiaer, M., Davis-Alldritt, L., Fekaris, N., Morgitan, J., Murphy, K., &Yow, B. (2011, April). Role of the school nurse. Retrieved from http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/87/Role-of-the-School-Nurse-Revised-2011

Nwabuzor, O. (2007, February). Legislative: "Shortage of Nurses: The School Nursing Experience." Online  Journal of Issues in Nursing Vol12 No 2. doi:10.3912/OJIN.Vol12No02LegCol01

Resha, C., (2010, May 31) "Delegation in the School Setting: Is it a Safe Practice?" OJIN: The

Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 5. doi:

10.3912/OJIN.Vol15No02Man05

The following is a script from "The Health Wagon" which aired on April 6, 2014. Scott Pelley is the correspondent. Henry Schuster and Rachael Kun Morehouse, producers.

President Obama announced last week that more than 7 million people have signed up for Obamacare. But what went unsaid is that almost as many people have been left out. Millions of Americans can't afford the new health insurance exchanges. For the sake of those people, Obamacare told the states to expand Medicaid, the government insurance for the very poor. But 24 states declined. So, in those states, nearly five million people are falling into a gap they make too much to qualify as "destitute" for Medicaid, but not enough to buy insurance. We met some of these people when we tagged along in a busted RV called the Health Wagon -- medical mercy for those left out of Obamacare.

As a health care giver, you have a responsibility to ensure that they have adequate knowledge in order to provide competent nursing care. Malcolm Gladwell wrote about “rapid cognition,” or our innate sense of “knowing” in his 2005 book, “Blink.” If you haven’t read it, I highly recommend it; it is a fascinating read for all nurses. Of it, Gladwell says:

“You could also say that it’s a book about intuition, except that I don’t like that word. In fact, it never appears in ‘Blink.’ Intuition strikes me as a concept we use to describe emotional reactions, gut feelings -- thoughts and impressions that don’t seem entirely rational. But I think that what goes on in that first two seconds is perfectly rational. It’s thinking -- it’s just thinking that moves a little faster and operates a little more mysteriously than the kind of deliberate, conscious decision-making that we usually associate with ‘thinking.’ In ‘Blink’ I’m trying to understand those two seconds. What is going on inside our heads when we engage in rapid cognition? When are snap judgments good and when are they not? What kinds of things can we do to make our powers of rapid cognition better?”

Within professional nursing, we call this concept “tacit knowledge.” It is not easily shared through lectures or books, but it comes with experience and knowing through repetitive, almost unaware situations and critical thinking. I explicitly learned about tacit knowledge (what an oxymoron) in my undergraduate nursing studies. However, I actually learned tacit knowledge while working with patients alongside more experienced nurses.

I picked it up from colleagues such as the night shift nurse, a LVN with 30 years of experience, who walked back to the desk after assessing a certain patient she’d cared for during the last three days saying, “I’m going to keep my eye on Mr. Second-Door-on-the-Left. I can’t put my finger on it, but I’m going to watch him.” As the oh-so-terribly-young charge nurse, I’d walk in and assess him, too, especially because I knew he was scheduled for discharge some time the next day. Not seeing what my colleague saw nor anything in the chart to cause alarm, I brushed it off only to think, What the…???, as we called a code in the wee hours of the morning -- in between patient rounds because my colleague increased her routine patient checks, “just because.” Similar situations have happened to me numerous times, and I have learned to trust members of the nursing community when they sense something going awry with a patient.

Tacit knowledge is one way to improve patient care, though it’s hard to explain when you know it as well as when you learn it. What a mysterious and fascinating concept and feeling.

Source: NurseTogether

By Neal St. Anthony

Registered nurse Rachele Simmons walked away from a $100,000 career two years ago.

She still isn’t generating enough cash to pay herself a salary from the St. Paul business she started in 2011. But if passion and commitment matter, Simmons already is wealthy from her mission to train and place more minorities in health care jobs.

And as business continues to grow at fledgling Foundations Health Career Academy, Simmons should generate positive cash flow by the end of this year.

“Rachele is phenomenal,” said Tom Thompson, administrator at St. Paul’s Galtier Health Center. “She’s positive and she knows what she is doing. We’ve hired some of her graduates and never had any problem. Her people are very good. And we have a diverse clientele in our facility. So we need staff who speak different languages and who are from different backgrounds and races.”

Simmons is the founder, teacher, marketer and chief bottle washer at Foundations Health, a state-certified private school that has graduated 160 students through its four-week, certified nursing assistant/home health aide program. For many graduates, the course offers a first step into the growing health care industry into jobs that can pay as much as $20 per hour plus benefits.

Simmons, 44, has been a hospital nurse and last worked as a manager at Walgreens, training managers and others to use retail-medical equipment. And she always worked a shift or two a week as a hospital nurse to build a rainy-day fund.

Over the years, Simmons got used to being the only black nurse on the floor or in managerial meetings at Walgreens.

She also knew that health care is a growth area, particularly lower-cost primary care that can be delivered relatively inexpensively outside the hospital and help keep patients in their homes.

She also thought she could be an inspiration to young people of color.

“I just wanted to give something back,” said Simmons, who decided, as her sons reached adulthood, she could handle some business risk. “I had been involved in nursing for 25 years. I was always the nurse called to see the ‘diverse’ patients, often black. It meant so much to them.

“This is what I was called to do. Maybe we can start something that … will get more people of color in nursing, in science, in medicine. We need more black nurses and Hmong nurses and more diversity in health facilities.” She’s even had a couple of white medical students take the class because they wanted to learn the grass roots and work in diverse clinics.

Foundations Health, housed in the Hmong Professional Building a mile west of the State Capitol on University Avenue, is a first business step for Simmons.

Simmons is no stranger to drive and hard work. Divorced when her sons were toddlers, Simmons said her ex-husband never paid child support, forcing her for a short time onto public assistance. The St. Paul Highland Park High School graduate completed two-year nursing school in St. Paul and worked days while completing her registered-nurse degree at Minneapolis Community and Technical College, often bringing her boys to play in the commons while she attended class.

“She was a successful nurse and thrifty with her money,” said Isabel Chanslor, a business trainer with nonprofit Neighborhood Development Center, which for 20 years has provided training to several thousand would-be urban entrepreneurs, including Simmons. “She did not want to take a loan.’’

Last month, NDC recognized Simmons for her commitment to community as a finalist in the organization’s annual entrepreneurial awards.

“She’s a gutsy lady,’’ Chanslor said. “She’s high energy, sharp, rides her little motor scooter everywhere. She has a good business plan and she’s a really good instructor and very focused and dedicated, according to her students.”

Simmons has invested $50,000 in space and equipment. She uses word-of-mouth and social media to attract students. The 80-hour course costs about $950.

“My students are mostly young, single, with kids, without kids, battered, not battered, on welfare, not on welfare … most of them are working poor,” Simmons said. “If they want to work hard and truly better their life, we’ll take them.”

Na Yang graduated from Foundations Health in 2011, but can’t work as a nursing assistant because of an injury. So, she joined the office as a part-time office manager.

Simmons said Yang works more hours than she’s paid because of her commitment to the cause and the need to stay on top of the paperwork.

“You couldn’t find a better instructor,” Yang said of Simmons.

“She’s knowledgeable and passionate. She couldn’t do this without her passion.”

Source: Star Tribune

By: The Advisory Board Company

The health care industry added 32,000 jobs in February, accounting for 13.6% of the 236,000 nonfarm jobs created last month, according to preliminary data released Friday by the U.S. Bureau of Labor Statistics (BLS).

In comparison, revised BLS data show that the health industry added just 13,000 jobs in January, partly because the agency now estimates that hospitals lost about 3,100 jobs in January.

Latest report shows hiring across industry

Within the health sector, physician offices and outpatient health centers experienced the biggest gains in February, adding about 14,000 jobs for the month, according to BLS. Meanwhile, ambulatory health care services added 13,700 jobs in February, down from 26,700 in January. 

The agency also found:

• Hospitals created 8,900 jobs in February;
• Home health care added 6,100 jobs, up from 5,700 new jobs in January; and
• Nursing homes added 9,000 new workers.

Overall, the national unemployment rate last month dropped to a four-year low of 7.7% (Selvam, Modern Healthcare, 3/8 [subscription required]; Baker, "Healthwatch," The Hill, 3/8).

As seen in The New York Times    

There is already a shortage of doctors in many parts of the United States. The expansion of health care coverage to millions of uninsured Americans under the Affordable Care Act will make that shortage even worse. Expanding medical schools and residency programs could help in the long run.

But a sensible solution to this crisis — particularly to address the short supply of primary care doctors — is to rely much more on nurse practitioners, physician assistants, pharmacists, community members and even the patients themselves to do many of the routine tasks traditionally reserved for doctors.

There is plenty of evidence that well-trained health workers can provide routine service that is every bit as good or even better than what patients would receive from a doctor. And because they are paid less than the doctors, they can save the patient and the health care system money.

Here are some initiatives that use non-doctors to provide medical care, with very promising results:

PHARMACISTS A report by the chief pharmacist of the United States Public Health Service a year ago argued persuasively that pharmacists are “remarkably underutilized” given their education, training and closeness to the community. The chief exceptions are pharmacists who work in federal agencies like the Department of Veterans Affairs, the Department of Defense and the Indian Health Service, where they deliver a lot of health care with minimal supervision. After an initial diagnosis is made by a doctor, federal pharmacists manage the care of patients when medications are the primary treatment, as is very often the case.

They can start, stop or adjust medications, order and interpret laboratory tests, and coordinate follow-up care. But various state and federal laws make it hard for pharmacists in private practice to perform such services without a doctor’s supervision, even though patients often like dealing with a pharmacist, especially for routine matters.

NURSE PRACTITIONERS In 2012, 18 states and the District of Columbia allowed nurse practitioners, who typically have master’s degrees and more advanced training than registered nurses, to diagnose illnesses and treat patients, and to prescribe medications without a doctor’s involvement.

Substantial evidence shows that nurse practitioners are as capable of providing primary care as doctors and are generally more sensitive to what a patient wants and needs.

In a report in October 2010, the Institute of Medicine, a unit of the National Academy of Sciences, called for the removal of legal barriers that hinder nurse practitioners from providing medical care for which they have been trained. It also urged that more nurses be given higher levels of training, and that better data be collected on the number of nurse practitioners and other advance practice nurses in the country and the roles they are performing. Tens of thousands will probably be needed, if not more.

Mary Mundinger, dean emeritus of Columbia University School of Nursing, believes highly trained nurses are actually better at primary care than doctors are, and they have experience working in the community, in nursing homes, patients’ homes and schools, and are better at disease prevention and helping patients follow medical regimens.

RETAIL CLINICS Hundreds of clinics, mostly staffed by nurse practitioners, have been opened in drugstores and big retail stores around the country, putting basic care within easy reach of tens of millions of people. The CVS drugstore chain has opened 640 retail clinics, and Walgreens has more than 350. The clinics treat common conditions like ear infections, administer vaccines and perform simple laboratory tests.

A study by the RAND Corporation of CVS retail clinics in Minnesota found that in many cases they delivered better and much cheaper care than doctor’s offices, urgent care centers and emergency rooms.

TRUSTED COMMUNITY AIDES One novel approach trains local community members who have experience caring for others to deliver routine services for patients at home. Two pediatric Medicaid centers in Houston and Harrisonburg, Va., have tested this concept to see if it can reduce the cost of home care and avoid unnecessary admissions to a clinic or hospital.

The aides are trained to consult with patients over the phone by asking questions devised by experts. A supervising nurse makes the final decisions on the care a patient requires. The community aide may visit the patient, provide care in the home and send photos or videos back to the supervising nurse by cellphone.

The aides are typically paid about $25,000 a year, according to an article in Health Affairs by the pilot study’s leaders. The study concluded that the program would have averted 62 percent of the visits to a Houston clinic and 74 percent of the emergency room visits in Harrisonburg.

The aides cost $17 per call or visit, compared with Medicaid payment rates of $200 for a clinic visit in Houston and $175 for an emergency room in Harrisonburg.

SELF-CARE AT HOME A program run by the Vanderbilt University Medical Center and its affiliates lets patients with hypertension, diabetes and congestive heart failure decide whether they want a care coordinator to visit them at home or prefer to measure their own blood pressure, pulse or glucose levels and enter the results online, where the data can be immediately reviewed by their primary care doctor. The patient could consult by phone or e-mail with a nurse about his insulin dosage, but there would be no need for a costly visit to a doctor.

Taking this idea a step further, a hospital in Sweden, prodded by a kidney dialysis patient who thought he could do his own hemodialysis better than the nursing staff, allowed him to do so and then teach other patients, according to the Institute for Healthcare Improvement, a nonprofit organization in Cambridge, Mass. Now most dialysis at that hospital is administered by the patients themselves. Costs have been cut in half, and complications and infections have been greatly reduced.

HEALTH REFORM LAW The Affordable Care Act contains many provisions that should help relieve the shortage of primary care providers, both doctors and other health care professionals.

It provides money to increase the number of medical residents, nurse practitioners and physician assistants trained in primary care, yielding more than 1,700 new primary care providers by 2015. It offers big bonuses for up to five hospitals to train advanced practice nurses and has demonstration projects to promote primary care coordination of complex illnesses, incorporating pharmacists and social workers in some cases. And it offers financial incentives for doctors to practice primary care — like family medicine, internal medicine and pediatrics — as opposed to specialties.

These are all moves in the right direction, but they will need to be followed by even bigger steps and protected from budget cuts in efforts to reduce the deficit.