Key Staff: Making Nursing Visible for Healthy Communities

Dr. Izumi is an experienced nursing researcher and educator with a track record of research and publications related to palliative care, quality of nursing care, testing and implementation of nursing care models. Her patient-centered care coordination model based on qualitative research findings described roles and practice of nurse care coordinators (2018) and is particularly relevant to design of this project. She will be the co-Project Director (co-PDs) and will co-lead the project including planning, conducting, analyzing, developing and piloting a new community-based nursing service model and disseminating findings from the project.

Dr. Mood has multiple years of experience as a nurse educator working in both academic and clinical contexts. Her research and scholarship is focused on population health and advancing health equity via innovation in education, research, and practice. She has prior experience as co-PD of a project of similar scope. On this project Dr. Mood will function as co-PD working closely with Dr. Izumi. Her time spent on this project will be dedicated to leading and managing the project including planning, conducting, analyzing, developing and piloting a new reimbursable and sustainable community-based nursing service model and disseminating findings from the project. She will take additional administrative and operational responsibility including data management and supervising the project staff.

As a nurse informaticist, she has experience and expertise to quantify and make nursing work visible using electronic health record (EHR) and operational data streams. She will play a critical role in mapping terminology of community-based nursing services with existing nursing terminology and specifying functional requirements for EHR documentation relate to billing. She will collect and analyze data integrating community nurses’ practice with standardize NANDA/NIC/NOC terminology, and specify the EHR functionality to support billing in Years 1 and 2. In Year 3, she will continue refining EHR functionality to capture community nurses’ practice and outcome measures for evaluation by working with a software developer in Adventist Health.

She has authored numerous publications including the books on nursing leadership and innovation in nursing. As a former director of care management in OHSU Hospital, she led a transitional care program (C-TraIn) where RNs and social workers were able to bill Medicaid for their service without using physician or APRN billing codes. Her program was cited in the “Future of Nursing 2020-2030” as a sole example of direct reimbursement for RNs. For this project, she will share her expertise to develop the billing mechanism by integrating nursing service into EHR and negotiate with multiple potential payers for reimbursement. She will also share documentation templates, descriptions of nurse care coordination practice, and assist to arrange interviews with nurse care coordinators to obtain descriptions of nursing practice and facilitators/barriers to implement nursing service as reimbursable service.

She has extensive experience in both clinical and administrative nursing in rural healthcare settings. She leads a group of outpatient clinic nurses who deliver CBNS in the local neighborhoods. For this project, Ms. Seufert will be a key project team member and the site program director at Adventist Health. She will share documentation templates, descriptions of community nurses’ practice, and assist to arrange interviews with community nurses. She will also accommodate site visits and collaboration with a software developer to adapt IS for billing.

Dr. Dawson is a health policy researcher with expertise in financing mechanisms for long-term services and supports (LTSS) and the analysis of policy implications related to interventions and programs for aging adults and people living with dementia. He will provide his expertise in the effort to explore financing mechanisms and reimbursement methods for nursing services.