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Nurs Admin Q Vol. 38, No. 2, pp. 128–132 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Meeting New Health Care Challenges With a Proven Innovation Nurse-Managed Health Care Clinics Denise G. Link, PhD, FAAN, FAANP; Diane Perry, MS, FNP; Evelyn L. Cesarotti, PhD, FAANP Beginning in January 2014, millions of Americans will enroll in health insurance plans under the Affordable Care Act. Some of these individuals were obtaining health care in safety net health clinics, emergency departments, or urgent care centers; many were going without needed care and will be new to the health care system. In addition to these newly insured, the ranks of older Americans and persons in need of chronic disease management will be on the rise. The way in which health care is delivered will have to change in order for the health care workforce to meet the demand for their services without sacrificing quality or access. Nurse practitioners and registered nurses have the education and skills to provide health promotion, disease prevention, and chronic disease management services that will make up a sizable portion of the demand. Amending state practice acts so that the authority to practice matches the ability to practice and opening provider panels to advanced practice nurses will provide opportunities to establish or expand sustainable nurse-led primary care practices in health care shortage areas. Along with these changes, models of health care delivery that incorporate differentiated practice roles and shared interprofessional responsibility for providing care will maximize the capacity of the system to provide the health care that people need. Key words: Affordable Care Act, differentiated practice, nurse-managed health care clinics

IMMINENT HEALTH ISSUES The Affordable Care Act will create an estimated 16 million newly insured people. While many of these individuals were already in

Author Affiliations: NP Healthcare–Grace Clinic (Dr Link) and Arizona State University (ASU) Health Services–Downtown–NP Healthcare (Ms Perry), ASU College of Nursing & Health Innovation, Phoenix (Dr Cesarotti). The ASU NP Healthcare–Grace Family Planning Program is funded in part by the US Department of Health and Human Services through the Arizona Family Health Partnership. The authors declare no conflict of interest. Correspondence: Evelyn L. Cesarotti, PhD, FAANP, Arizona State University College of Nursing & Health Innovation, 500 N 3rd St, Phoenix, AZ 85004 ([email protected]). DOI: 10.1097/NAQ.0000000000000004

the health care system in safety net clinics, urgent care centers, and emergency departments, they will now have insurance coverage and will likely be in search of health care services through more mainstream health care providers, adding stress to an already overburdened and understaffed primary care workforce in the public and private sectors.1 The Affordable Care Act provides nurse practitioners (NPs) with the opportunity to “lead and contribute to the redesign of healthcare delivery models focused on wellness and prevention.”2 Nurse-managed clinics and NPs are at the forefront of providing care to vulnerable populations. Under the Affordable Care Act, millions of young adults, up to the age of 26 years, have gained coverage under their parents’ health insurance and will continue to be covered. In addition, those younger than

128 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Meeting New Health Care Challenges With a Proven Innovation 19 years can no longer be denied coverage because of preexisting conditions. New health insurance plans will also be required to provide certain preventive services at no cost to consumers, including mammograms, immunizations, and colonoscopies.2 Advanced practice registered nurses are educated to provide preventive, primary, and transitional care to individuals across the life span. Nurse practitioners, who have already demonstrated the ability to provide safe, highquality, cost-effective care, could be a significant health care resource in this developing crisis of access to health care. Mounting studies indicate the quality of NP care is equal to or higher than other health care providers and at a lower cost. Nurse practitioners have received specific education in communicating with patients and preventive health interventions, and studies have demonstrated their excellence in these skills.3 However, despite convincing data about the quality of care provided by NPs, the majority of state practice acts prohibit the ability of NPs to practice autonomously because of the existence of statutory requirements to practice under the supervision of a physician or in a collaborative relationship.4 Supervisory and collaborative practice requirements limit the ability of NPs to start practices in areas where there is a shortage of primary care providers. In some areas, NPs have been unable to secure an agreement with a physician or have had to pay a physician to provide the required supervision or collaboration. As a result, NPs who are willing to open or expand a practice in an area where care is needed may be unable to do so because of legal or financial barriers.5 In addition, many managed care organizations across the country do not credential NPs as primary care providers so that NPs are unable to be directly reimbursed by private insurers.6 Exclusion from insurance network provider panels inhibits insured patients’ access to a larger pool of qualified health care providers and blocks NPs’ access to revenue that could be used to create, sustain, or expand a clinical practice enterprise.

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ARIZONA Arizona has a critical shortage of health care providers in primary care. This comes at a time when the demand for comprehensive primary care and chronic disease management is increasing with the complex needs of an aging population; currently, 15% of the Arizona population is older than 65 years.7 As of June 30, 2010, 15% of Arizona residents were Medicare beneficiaries and the number is increasing. Every county in Arizona has significant number of primary care medically underserved areas. Arizona is 1 of the 18 states and the District of Columbia where NPs are independently licensed and certified in 1 or more specialty areas with prescriptive privileges that include controlled substances. Yet, expanding and increasing NP-led practices in Arizona are restricted because of the aforementioned inability to join insurance provider networks. According to the National NP Database of the American Association of Nurse Practitioners, 48.4% of the respondents from Arizona indicated that their main focus was Family Nurse Practitioner and 8% indicated that they practice in communities with populations of less than 25 000.8 As of February 13, 2014, the Arizona Board of Nursing indicates that there are 4,521 NPs, 213 certified nurse midwives, and 203 clinical nurse specialists licensed to practice in Arizona. The NP to population ratios in the urban counties are 38 per 100 000; ruralurban counties 40 per 100 000, and rural-rural 9 26 per 100 000. Nurse practitioners in primary care specialties—family practice, adult health, women’s health, and pediatrics—are educated to make critical judgments at all levels of prevention, including health promotion; illness prevention; and diagnosis and management of individuals, families, communities, and populations. The NP performs comprehensive health assessments and diagnoses of illness and prescribes pharmacologic and nonpharmacologic treatment to manage acute, self-limited, and chronic health problems to achieve quality cost-effective outcomes in a

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culturally sensitive context. The roles of the NP includes educating, consulting, and collaborating, using research and expert panel recommendations to make practice decisions, and influencing professional and public policies that directly or indirectly impact the health in individuals, families, and communities. Within various practice settings, the NP provides health care across the life span within a legally defined scope of practice. NURSE PRACTITIONER–MANAGED HEALTH CLINICS Esperat et al10 stated that the Division of Nursing of the Health Resources and Services Administration has data to support the findings that NP-managed clinics (NMHCs) can be a significant component of the primary health care system in providing access particularly for underserved and vulnerable populations in need of a consistent, patient-centered, and affordable source of health care. However, they also cautioned that the financial challenges facing NMHCs are significant and that there need to be policy changes to allow NMHCs to survive within the competitive health care climate. This is the dilemma that we are faced with trying to maintain our 2 clinics at Arizona State University (ASU). ASU NP Healthcare–Downtown Phoenix The Downtown Phoenix Campus Health Center is 1 of the 2 community clinics from what was at one time a system of 4 clinics that began in 1977 with 1 clinic. NP Healthcare– Downtown Phoenix opened its doors in the fall of 2006. It was the first campus-based student health clinic to be under the administration of the College of Nursing and the first to be permitted to provide health care on a nonemergency basis to ASU employees and the public. NP Healthcare–Downtown Phoenix, now called ASU Health Services–Downtown– NP Healthcare, is the first ASU campus health service to offer fully integrated physical and mental health care services and staffs an

interdisciplinary team of family NPs, adult health NPs, psychiatric mental health NPs, clinical psychologists, registered nurses, and medical assistants. NP Healthcare–Downtown Phoenix serves the health care needs of the faculty, staff, and students on the ASU Downtown Phoenix campus and many downtown businesses and government offices. Using a patient-centered, integrated, and interdisciplinary health model, staff members deliver primary health services with the goal to promote, maintain, and/or regain optimal health. The staff provides checkups for routine health care and evaluation of minor illnesses and health problems, health screening based on personal lifestyle and family health history, personal advice, and educational programs to promote and/or maintain health. This enables the NPs to become the primary care providers for these patients. ASU NP Healthcare–Grace NP Healthcare–Grace began in 1991 as an NP-managed mobile pediatric practice supported by state Tobacco Tax settlement funds. In 2001, the focus of the practice changed to family planning and NP Healthcare–Grace is now a DHHS (Department of Health and Human Services)/Title X–funded nurse-managed clinic located in central Phoenix. The practice model is a unique collaboration among state and federal government entities, an independent nonprofit agency and a faith-based organization. In addition to the participation of ASU and Title X, the clinic partners include the Arizona Family Health Partnership (the nonprofit) and Grace Lutheran Church, which provides the space for the clinic in one of its buildings. The clinic staff serves women, men, and adolescents who are low-income and either uninsured or enrolled in the state Medicaid program. Free or low-cost family planning and related services are available to underserved populations in Phoenix and the surrounding area; the clinic staff is bilingual (Spanish-English). The clinic hosts dozens of health professions students throughout the

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Meeting New Health Care Challenges With a Proven Innovation academic year for supervised clinical experiences, and there are opportunities for faculty practice and research. Grace serves a population in which 98% of clients live at or below the federal poverty level and 74% speak only Spanish. In 2013, NP Grace clinic served 1871 unduplicated clients in 3416 client visits. Providing health care for the uninsured in community settings reduces emergency department use for nonurgent needs; providing culturally appropriate, barrier-free family planning services reduces the incidence of unintended pregnancy, enables family members to enter the workforce and pursue education or job training, and improves the health of mothers and babies.11,12 Patients whose income is 100% or less of the federal poverty level may obtain services and contraception for a donation. For patients whose income is between 100% and 250% of the federal poverty level, fees are based on income. LEADING FOR FUTURE HEALTH CARE DELIVERY One of the major differences in our NMHC operations is the emphasis on differentiation of practice and shared responsibility for patient-focused care. Workflows and operations are organized around the unique aspects of each staff member’s role and insuring that all members are empowered and able to practice to the full extent of their education, training, and/or license. For example, the extensive utilization of medical assistants under the supervision of an NP to provide patient education, initial intake, medication administration, and Clinical Laboratory Improvement Amendments waived testing is standard practice at our clinics. Upon hire and on an ongoing basis at the Grace Clinic, the medical assistants are thoroughly educated in best practices in family planning and routine office testing at the level of their education and abilities. They complete an initial standardized training program that includes classroom instruction and testing for knowledge and comprehension. They must also pass an oral examina-

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tion with a standardized patient to demonstrate their knowledge of family planning basics and accepted practices for interviewing a patient. Mandatory annual in-service and periodic continuing education assists the staff to maintain and enhance clinical and customer service skills. The staff shares the work of moving the patient through the office encounter in a way that all employees are accountable for making sure that the patient’s visit is patient-centered, safe, thorough, and documented. The shared responsibility ensures that there is a system of checks and balances and the knowledge that if some practice or process needs to be changed or corrected, the staff members will bring those situations to each other’s attention with courtesy and professionalism. The concepts of shared responsibility and differentiation of practice are part of the nursing model that is taught in baccalaureate nursing education and carried on into practice. Since the model has been implemented, we have been able to increase the number of unduplicated clients seen by 50% and reduce the time that patients spend in the clinic. This means a lot to clients who are on limited budgets and who have taken time off from work— time that they often are not paid for. It also means that more underserved clients are able to access health care in a timely way. The quality of care has not suffered as the result of these increased efficiencies; our staff is consistently recognized by our oversight agency for meeting or exceeding quality benchmarks for family planning services set by the Title X program. For example, the staff has met the standard for Chlamydia testing for 100% of clients who meet the criteria established by the Centers for Disease Control and Prevention. CONCLUSIONS Registered nurses practicing at the top of their license as recommended in the Institute of Medicine/Robert Wood Johnson Foundation “Future of Nursing” report also have a role in expanding access to primary

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care. They can be a valuable asset to a busy primary care practice by providing the billable services that the MAs must be supervised to perform. In that way, registered nurses can free the MAs to provide the nonbillable services and enable the NP to provide additional high-level evaluation and management services instead of supervising the MAs or doing tasks that RNs can do and be reimbursed. Another area that needs more em-

phasis is the use of interprofessional teams, with NPs contributing an integral role to provide high-quality, coordinated, and optimal care. Examples of new areas that are successively using team care are palliative care clinics13 and combined nurse-pharmacist– managed pain clinics.14 Under the growing pressures to balance quality and cost of health care, nurse-managed clinics can be a vital part of the solution.

REFERENCES 1. Hansen-Turton T, Ware J, Bond L, Doria N, Cunningham P. Are managed care organizations in the United States impeding the delivery of primary care by nurse practitioners? A 2012 update on managed care organization credentialing and reimbursement practices [published ahead of print March 29, 2013]. Popul Health Manag. 2013;6(5):306-309. doi:10.1089/pop.2012.0107. 2. Knudson L. Affordable Care Act Ruling Introduces Sweeping Changes to Health Care System. Denver, CO: Association of periOperative Registered Nurses; 2012. http://www.aorn.org/News.aspx?id= 23413. Accessed August 5, 2013. 3. American Association of Colleges of Nursing. Nurse practitioners: the growing solution in health care delivery. http://www.aacn.nche.edu/media-relations/ fact-sheets/nurse-practitioners. Accessed August 5, 2013. 4. Cassidy A. Health policy brief: nurse practitioners and primary care. Health Aff. http://www.healthaffairs .org/healthpolicybriefs/brief.php?brief_id=92. Updated May, 15, 2013. Accessed August 5, 2013. 5. Gebbe K. Laws are not the only barriers to scope of practice. RWJF Human Capital Blog. http://www .rwjf.org/en/blogs/human-capital-blog/2011/10/lawsare-not-the-only-barriers-to-scope-of-practice.html. Accessed August 5, 2013. 6. Yee T, Boukus E, Cross D, Samuel D. Primary Care Workforce Shortages: Nurse Practitioner Scope-ofPractice Laws and Payment Policies. Washington, DC: National Institute for Healthcare Reform; 2013. NIHCR Research Brief No. 13. 7. Center for Medicare & Medicaid Services. Population denominators for 2012. http://www.azdhs.gov/

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plan/menu/info/pop/pop12/pd12.htm. Published 2012. Accessed January 31, 2013. Goolsby MJ. National Nurse Practitioner Database. Austin, TX: American Association of Nurse Practitioners; 2012. American Nurses Association. Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data. http://www .nursingworld.org/APRNdistributionreport. Published February 2012. Accessed October 16, 2013. Esperat MC, Hanson-Turton T, Richardson M, Tyree Debisette A, Rupinta C. Nurse-managed health centers: safety-net care through advanced nursing practice. J Am Acad Nurse Pract. 2012;24(1):24-11. Gribble J, Graff M. Family Planning Improves the Economic Well-being of Families and Communities. Washington, DC: Population Reference Bureau. http://www.prb.org/Articles/2010/ bangladeshfp.aspx. Accessed August 5, 2013. Canning D, Schultz TP. The economic consequences of reproductive health and family planning. Lancet. 2012;380:165-171. Owens D, Eby K, Burson S, Green M, McGoodwin W, Isaac M. Primary palliative care clinic pilot project demonstrates benefits of a nurse practitionerdirected clinic providing primary and palliative care [published online ahead of print September 4, 2011]. J Am Acad Nurse Pract. 2012;24(1):52-58. doi:10.1111/j.1745-7599.2011.00664.x. Hadi MA, Alldred DP, Briggs M, Closs SJ. A combined nurse-pharmacist managed pain clinic: joint venture of public and private sectors. Int J Clin Pharm. 2012;34(1):1-3. doi:10.1007/s11096-011-9591-1.

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Meeting new health care challenges with a proven innovation: nurse-managed health care clinics.

Beginning in January 2014, millions of Americans will enroll in health insurance plans under the Affordable Care Act. Some of these individuals were o...
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