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Background Our health care system is facing unprecedented and complex challenges in caring for older adults and their families. A paradigm shift is needed that recognizes new roles and competencies for nurses to play a leadership role in the design and implementation of high value care models. Purpose The purpose of this paper is to introduce a series of recommendations for leveraging nurses to generate innovative tools and solutions for the delivery of value-based care for older adults living with complex health and social needs and their families. Methods These recommendations were generated by a Think-Tank of national experts based on review of current evidence and focus groups with older adults. Finding The generated recommendations focus on positioning nurses to assume leadership roles in implementing evidence-based care models, preparing nurses to serve as health innovators and catalysts of system transformation, and fostering system-level infrastructure that leverages the contributions of nurses for current and emerging roles. Discussion Nurses as innovators can address the challenges in providing high quality care for older adults with complex needs and their families. System-level infrastructure, including resources for training and implementation of well-established programs, is necessary to leverage the contributions of nurses and facilitate innovative approaches to care.

Care coordination and transitional care services are strategically important for achieving the priorities of better care, better health, and reduced costs embodied in the National Strategy for Quality Improvement in Health Care (National Quality Strategy [NQS]). Some of the most vulnerable times in a person’s care occur with changes in condition as well as movement within and between settings of care. The American Academy of Nursing (AAN) believes it is essential to facilitate the coordination of care and transitions by using health information technology (HIT) to collect, share, and analyze data that communicate patient-centered information among patients, families, and care providers across communities. HIT makes information accessible, actionable, timely, customizable, and portable. Rapid access to information also creates efficiencies in care by eliminating redundancies and illuminating health history and prior care. The adoption of electronic health records (EHRs) and information systems can enable care coordination to be more effective but only when a number of essential elements are addressed to reflect the team-based nature of care coordination as well as a focus on the individual’s needs and preferences. To that end, the AAN offers a set of recommendations to guide the development of the infrastructure, standards, content, and measures for electronically enabled care coordination and transitions in care as well as research needed to build the evidence base to assess outcomes of the associated interventions.

The University of Pennsylvania School of Nursing has established a community-based practice based on a model of socially responsible care and designed to meet the complex care needs of frail elders.

Alliances for academic home care offer a new approach to advance the knowledge base related to home care, improve quality and cost-effectiveness of home care services, prepare the next generation of providers to manage and deliver care in a restructured practice paradigm, and influence health and social policy.

Gerontological nursing research is critical for developing the science that will be needed to provide the evidence base required to care for the unprecedented growth of the older adult population in the 21st century. This article describes the research initiatives of the 5 Hartford Centers of Geriatric Nursing Excellence (HCGNE), the key features that made them successful, the lessons learned, the challenges during implementation, and the outcomes; it concludes with conclusions and recommendations. The HCGNE developed highly successful initiatives to increase gerontological nursing research capacity focused on assisting faculty and students to write and conduct pilot studies. Key features of these initiatives included mentoring by senior gerontological nurse researchers over an extended period of time, dedicated time free from the demands of teaching, and financial support, either in the form of money or release time from regular responsibilities. The research initiatives described in this article can serve as models upon which other schools can build their own initiatives, based on their own strengths and resources. Ongoing strategies to increase gerontological nursing research are needed at both the national and individual school levels.

This article examined the activities and outcomes of Health Centers for Geriatric Nursing Excellence (HCGNE) initiatives over the last 5 years in health policy designed to improve the care for older people. Qualitative data were collected from the 5 HCGNE describing their policy initiatives. The findings showed that HCGNE initiatives included a wide range of policy actions designed to improve access to appropriate geriatric nursing care, improve nursing home quality, develop new models of care delivery, improve the safety and cost effectiveness of transitions from hospital to home, and develop consumer information systems about quality. In addition, HCGNE developed educational courses and programs in health policy with research and policy analysis experiences. Faculty and students were involved in policy and leadership activities at the local, state, and national levels. The HCGNE brought gerontological research knowledge, clinical expertise, and policy experience to the policy arena that resulted in needed policy changes to improve geriatric care. Policy initiatives are key to making long-term system changes that can result in improvements in the access, quality, and costs of care for older people.

The curriculum that was described in this article reflects our school's broad and bold definition of what constitutes knowledge in nursing. It also represents the faculty's dedication to a creative approach to education and practice, as well as a commitment to change in an age of change. It portrays a desire to design education that would develop the full range of human potential, the full potential of the university, and incorporate the full range of approaches to human problems. Our current changing practice environment underscores the challenges and complexities facing faculties and student nurses in pursuit of relevant and useful theoretic and clinical content. In addition, those of us who have practiced in the psychiatric field know that the care of clients with psychiatric problems requires heterogeneous approaches to treatment that vary with respect to type, frequency, severity, and chronicity of their conditions. We know that the impact of certain conditions is linked to age and developmental status, and we know that the effects of deviations from health are mediated by numerous features of ecology, including poverty, job and family instability, parental stress, social isolation, and community violence. As a result, nursing interventions and their outcomes no longer can be viewed in terms of simple cause and effect relationships; nor can they be thought of as occurring in the familiar settings of hospitals or institutions. For better or worse, those facilities have closed. This reality and the enormous complexities of human science speak to the multidimensional factors involved in the construction of new and different models of teaching and learning within a comprehensive conceptual framework to guide both learning and practice.