6.4 Care Delivery Models, Top-of-License Practice & Population Health
Key Takeaways
Care delivery models—total patient care, functional, team, primary, modular, case management and virtual nursing—trade off continuity, cost, skill mix and coordination.
Primary nursing gives one RN 24-hour accountability for a patient's plan of care from admission to discharge.
Top-of-license practice aligns tasks with education and licensure and moves non-nursing work to support roles, so more RN time goes to direct care.
Population health, defined by Kindig and Stoddart as outcomes for a group including their distribution, relies on risk stratification, care coordination and attention to social drivers.
CMS's mandatory TEAM model, running since January 1, 2026, makes selected hospitals accountable for five surgical episodes through 30 days after discharge.
6.4 Care Delivery Models, Top-of-License Practice & Population Health
The first task in the CENP outline's Health Care Environment domain is to transform care delivery models and environmental design so that care is safe, evidence-based, accessible, affordable and equitable. The same domain asks executives to use a population health approach, and the Business Skills domain asks them to advance policies that let staff practice at the top of their education and license. This section brings those threads together.
Nursing Care Delivery Models
A care delivery model defines who does what for which patients, and who is accountable for the plan of care. Every model trades off continuity, cost, skill mix and coordination.
| Model | How work is organized | Strengths | Limitations |
|---|---|---|---|
| Total patient care | One RN provides all care for assigned patients during a shift | Holistic, simple accountability | Costly; continuity ends at shift change |
| Functional nursing | Tasks are divided by function (medication nurse, treatment nurse, aides for hygiene) | Efficient with few RNs | Fragmented care; no one sees the whole patient |
| Team nursing | An RN team leader directs LPNs and assistive personnel for a group of patients | Uses mixed skill levels; supervision built in | Depends on strong team leadership; communication load |
| Primary nursing | One RN (the primary nurse) holds 24-hour accountability for a patient's plan from admission to discharge; associates carry it out on other shifts | Continuity and clear accountability | Needs a high RN mix and stable staffing |
| Modular / partnership | Small geographic modules or RN–assistant pairs share a group of patients | Reduces walking and handoffs | Requires careful role definition |
| Care coordination / case management | Nurse case managers or navigators coordinate care across settings for defined populations | Improves transitions and resource use | Adds roles that must be funded |
| Virtual nursing | Remote RNs handle admissions, discharge teaching and monitoring alongside bedside teams | Extends experienced nurses; supports novices | Technology cost; role clarity needed |
Primary nursing is associated with Marie Manthey, who developed it at the University of Minnesota Hospitals in the late 1960s. Many organizations now use hybrid models—for example, team-based care with an RN, LPN and assistant, supported by a virtual nurse—chosen to fit acuity, skill mix and the workforce available. Executives should judge any redesign by quality and safety outcomes, patient experience, staff experience, cost and equity, and should pilot changes before spreading them.
Practicing at the Top of License
Top-of-license practice means each person does the work that requires their education and license, and delegates or redesigns the rest. Executive levers include:
- Role clarity: Map tasks against state scope of practice for RNs, LPNs, assistive personnel and advanced practice registered nurses (section 4.4), and remove non-nursing tasks from RN assignments—transport, supply restocking, routine clerical work.
- Delegation infrastructure: Competency validation for delegatees, clear policies and supervision expectations based on the NCSBN/ANA delegation guidelines.
- APRN privileges: Medical staff privileges and protocols that allow APRNs to practice to the full extent of state law.
- Support services: Pharmacy, supply chain and environmental services designed so nurses are not filling gaps.
- Measurement: Time-and-motion or EHR-log studies of how much RN time goes to direct care, before and after redesign.
Increasing nursing time at the bedside is named in the CENP outline as a complex executive challenge. Typical strategies combine waste removal (section 5.4), technology that reduces documentation burden (section 14.3), virtual nursing support and redesigned support roles—while monitoring workload so that freed time actually reaches patients.
Evidence-Based Environmental Design
The physical environment affects safety, efficiency and experience. The evidence-based design movement (associated with the Center for Health Design) applies research to decisions such as:
| Design feature | Evidence-informed rationale |
|---|---|
| Single-patient rooms | Easier infection control, privacy, family presence and less noise |
| Decentralized nurse stations and alcoves | Less walking and better visibility of patients |
| Standardized ("same-handed") room layouts | Predictable locations for equipment, reducing errors |
| Handwashing sinks and sanitizer at the point of care | Better hand hygiene |
| Lighting, noise control and views of nature | Better sleep, less stress and possibly fewer falls and errors |
| Family zones in patient rooms | Supports family presence and partnership in care |
Executives involve frontline nurses, patients and infection preventionists early in design, use simulations or full-scale mock-ups before construction, and evaluate occupied spaces afterward.
Population Health
Population health was defined by Kindig and Stoddart (2003) as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." A population health approach shifts the executive's focus from individual encounters to defined populations—a community, a payer's members or patients with a shared condition.
Core elements:
- Define the population and its needs, using data such as the community health needs assessment (section 1.4) and social-needs screening (section 11.2).
- Stratify risk, so that high-risk patients receive care management while lower-risk patients receive prevention and self-management support.
- Coordinate across the continuum—primary care, specialty care, post-acute care, home health and community services—with nurse-led transitions and follow-up.
- Address social drivers of health through community partnerships.
- Measure outcomes for the whole population, including disparities.
Payment Models That Reward Population Health
Population health strategies are reinforced by alternative payment models that move risk from payers to providers:
| Model | How it works | Nursing implications |
|---|---|---|
| Accountable care organizations (e.g., the Medicare Shared Savings Program) | Providers share savings (and sometimes losses) when total cost of care for attributed patients is below a benchmark and quality standards are met | Care coordination, transitions and chronic disease management |
| Bundled / episode payments | One target price covers an episode of care across settings | Discharge planning, post-acute coordination, complication prevention |
| Capitation | A fixed amount per member per period covers defined services | Prevention and keeping members healthy become financially valuable |
Since January 1, 2026, CMS has run the mandatory Transforming Episode Accountability Model (TEAM) for selected acute care hospitals. Participants are accountable for the cost and quality of care for Traditional Medicare patients from certain surgical procedures—lower extremity joint replacement, surgical hip and femur fracture treatment, spinal fusion, coronary artery bypass graft and major bowel procedures—through 30 days after discharge. TEAM rewards exactly the nursing contributions this section describes: preventing complications, planning discharges, coordinating post-acute care and following up after the patient goes home.
Which feature distinguishes primary nursing from team nursing?
Remote nurses complete admissions and discharge teaching to support the bedside teams on each unit
Tasks are divided by function, such as a medication nurse, a treatment nurse and aides for hygiene
One RN is accountable around the clock for a patient's plan of care from admission to discharge
An RN team leader directs LPNs and assistive personnel who share the care of a group of patients
A CNO finds that medical-surgical RNs spend substantial time transporting patients, restocking supplies and processing paperwork. Which action best advances top-of-license practice?
Replace RNs with assistive personnel for all care except medication administration and assessment
Raise the RN-to-patient ratio so that nurses have more time for the non-nursing tasks they already do
Redesign support roles and services so non-nursing tasks shift away from RNs, then measure direct-care time
Ask RNs to work faster during peak hours and to complete clerical work after their shift ends
A hospital selected for CMS's Transforming Episode Accountability Model (TEAM) wants to improve performance for its joint replacement episodes. Which nursing strategy most directly targets the model's accountability?
Strengthening discharge planning, post-acute coordination and follow-up through 30 days after discharge
Lengthening inpatient stays so that every patient is fully recovered before going home or to rehabilitation
Increasing the number of elective joint replacement cases scheduled each week to raise surgical volume
Focusing only on intraoperative efficiency, because TEAM measures the surgical procedure itself and nothing else
Sections you finish are checked off in the contents.