It’s just after lunchtime at Community Clinic Inc. (CCI), a federally qualified health center in Takoma Park, Maryland, a Washington, DC, suburb with a large immigrant and refugee population. Team Nurse Jose Aguiluz, RN, leads the afternoon huddle, a daily ritual where primary care providers—physicians and nurse practitioners—discuss their most complex cases with other members of the clinical team, including community health workers, medical assistants, and Aguiluz himself.
The huddle’s purpose is to spotlight patients with multiple conditions that need to be carefully monitored. The team identifies those who may benefit from “care management,” an approach that combines intensive patient education, follow-up calls and visits, and coordination with specialists. Most of CCI’s patients are low-income and face significant barriers to care, including a lack of transportation, lack of health insurance for those not covered by Medicaid or Medicare, lack of family support like child or elder care, poor nutrition, and mental health complications.
Today’s discussion, for example, includes a woman with bipolar disorder, schizophrenia, and breast cancer who is leery about undergoing a mastectomy and an encephalopathic patient who is convinced he has been followed for the past 20 years.
Care management at CCI has been in the works for two years, ever since the organization decided to become a “patient-centered medical home,” where patients follow a treatment plan and are cared for by a multidisciplinary team of professionals, led by a doctor or nurse practitioner.
Care management, or care coordination as it is also called, is intended to keep patients healthy and is one of the guiding principles of the Affordable Care Act (ACA), President Obama’s signature health care law passed in 2010. In addition to requiring everyone to carry health insurance starting this year, the ACA attempts to lower costs by discouraging episodic care and incentivizing care that anticipates acute illness before it occurs.
“The focus now is on preventative care,” says Aguiluz, who fields daily inquiries about the ACA from patients. “The questions we’re asking ourselves is: How are we treating chronic conditions? How do we prevent people from seeking care in the hospital?”
Nurses will play an instrumental role in an evolving health care system brought forth by the ACA. The law presents both opportunities and challenges to both registered nurses and advanced practice nurses since both groups will be called upon to meet the needs of newly insured patients seeking care on a more regular basis.
Nurses will be integral not only on care coordination teams as both managers and clinicians, but also in a more robust primary care sector the ACA mandates. Health policy experts question whether there will be an adequate supply of primary care providers with fewer medical students pursuing careers in primary care. Nurse practitioners are eager to fill the need—particularly in underserved communities—but face unique battles when it comes to being uniformly embraced in primary care roles.
The Role of RNs in Care Coordination
According to the Department of Health and Human Services, health centers like CCI are expected to be a testing ground for how well the ACA works since they serve as a magnet for uninsured patients. Some of CCI’s uninsured will now be eligible for Medicaid while others will qualify for subsidies to purchase individual policies. The ACA set aside $11 billion for health centers nationwide, although no funds are specifically designated for care management. Navigators have been hired or contracted by many health centers to assist patients shopping for insurance on the online health care exchanges.
“If you look at the law, it talks about shifting care into the community away from hospitals,” says Susan Hassmiller, PhD, RN, FAAN, senior advisor on nursing at the Robert Wood Johnson Foundation. “In my mind, nurses are the ideal people to deliver care in this changing model. We need people who can take care of patients holistically, over their lifetime. ”
Health centers have hired more nurses in recent years not in direct anticipation of the ACA, but as a result of structural changes to the way they serve clients. Since CCI began its transformation into a medical home nearly two years ago, its nursing staff has grown from two to 10, says Shobhna Shukla, RN, MSN, FNP, clinical programs director at CCI. The “linchpin” of each clinical team at each of CCI’s seven locations, nurses could be a determining factor when newly insured consumers select a primary care provider, explains Shukla.
“Health centers are often measured by the quality of their nursing staff,” she adds. “What we do with nurses here…is going to be very important in terms of when people make choices about where to go.”
For years, Andrew Swiderski, MD, MPH, a pediatrician at CCI, felt frustrated by his inability to keep up with the “big pile of chronic issues” presented by certain patients—asthma, obesity, allergies, and diabetes among them. Now that care management is part of CCI’s culture, a dedicated RN and community health worker help Swiderski’s patients navigate the maze of specialist referrals, prescriptions, and other preventative services they need. It frees Swiderski to focus on the patient’s immediate medical issue in the short window of time he has with them.
“I feel so much better about what I do,” says Swiderski. “I don’t have to feel guilty about patients who need constant follow-up.” After Swiderski’s visit with a patient, the team nurse spends time educating the patient and his or her family about the next steps in their treatment plan.
“It’s amazing the depth [the team nurse] covers,” he says.
Empowering the Uninsured
The medical home model being implemented at health centers around the country and guidelines set forth by the ACA are, in many ways, complementary, says Margarita Sol, RN, the nursing care coordinator who oversees care management efforts at each of CCI’s seven clinics. Both initiatives prioritize access to health care, care coordination, prevention, health outcomes, and choice. “Choice means it’s patient-centered,” she adds.
In Maryland, like other states who opted to expand Medicaid, patients who previously didn’t qualify for the program will be eligible now. Meanwhile patients who earn too much for Medicaid could receive subsidies to purchase insurance on the exchange.
While they can’t predict how many new patients they’ll see as a result of the law, CCI clinicians say current patients who are self-paying are likely to benefit from expanded insurance options. They won’t have to shoulder the cost of necessities like labs, visits to specialists, and medical supplies or equipment entirely on their own.
“There is a pool of patients who have been waiting for more care outside of our clinic [that] has been on hold or at a sluggish pace,” says Sol. Now, adds Shukla, “they won’t have to delay if they don’t have the cash.”
Ruth Jackson of Brandywine, Maryland, knows firsthand the anxiety that comes with delaying care. Jackson, 41, is an uninsured single adult and a full-time student who pays for her own medical expenses. Before she became uninsured, her primary care doctor noticed her thyroid was enlarged. By the time Jackson got around to scheduling an MRI, she had quit her job so she no longer had health insurance. She paid $200 for the MRI, which revealed nodules on her thyroid. Jackson has since postponed a biopsy of the nodules because she can’t afford one.
“It’s worrisome,” she says. “I don’t know if my condition has gotten worse.”
Before starting a master’s degree in public administration, Jackson’s goal was to keep working while pursuing her studies. Then her parents became bedridden and wheelchair-bound, and Jackson became their full-time caregiver. Faced with a choice of having employer-sponsored health insurance or caring for her parents, she chose the latter.
For her master’s thesis, Jackson is writing about the experience of uninsured consumers—herself included—using the online health exchange. Her research focuses on clients of Greater Baden Medical Services, a Brandywine-based community health center where 44% of patients are uninsured, according to Colenthia Malloy, chief executive officer. Jackson also serves as a client representative on Greater Baden’s Board of Directors.
To Jackson, the ACA’s long-term promise is that “every person including myself will have access to care,” which means she’ll have better control over her asthma and will be able to visit a dentist, whom she hasn’t seen in two years. In the short term, she says, having insurance means “being able to determine whether I have cancer.”
Nurses, Jackson says, can play an influential role in educating consumers about how the ACA benefits them. One nurse-managed health center in Baltimore is doing just that. The East Baltimore Community Nursing Centers are in the process of becoming training sites for navigators who will assist clients sign up for health insurance, says Patty Wilson, RN, MSN, director of the centers.
Some of the centers’ clients are having difficulty enrolling, particularly with technical glitches in the Maryland health exchange website. Also, clients don’t prioritize purchasing insurance as work and family obligations take up most of their time. While they “have other things on their plate,” says Wilson, each center’s goal is to assist clients “become advocates for their own health care.”
Nurse Practitioners and the Primary Care Workforce
At Unity Health Care, a federally qualified health center in Washington, DC, the number of nurse practitioners occupying slots as primary care providers has grown from a “handful” to about 50 across Unity’s clinics in DC, says Sarah Price, RN, MSN, director of nursing development. While MDs make up the majority of providers at Unity, nurse practitioners have their own patient panels and are “very independent and focused on primary care,” she says.
“We weren’t able to be where we are in terms of thinking outside the box without hiring nurse practitioners,” says Malloy of Greater Baden Health Services, which will extend hours at all their clinics this year to keep up with demand. Nurse practitioners make up 30% of Greater Baden’s providers.
According to the American Association of Nurse Practitioners (AANP), 89% of nurse practitioners receive training in a primary care specialty, including family medicine, pediatrics, and women’s health. And while the AANP reports growth in enrollment and graduation rates for nurse practitioners, other experts say the shortage of faculty and the lack of clinical training opportunities and dedicated mentorship cripple the ability of nursing schools to contribute meaningfully to the primary care workforce.
Unlike family physicians, nurse practitioners in primary care don’t undergo a residency program before taking on their own patients. Nurse practitioners from earlier generations usually earned their advanced degrees after years working in a clinic or hospital as a registered nurse. Newer graduates, however, are heading straight to graduate programs with fewer clinical experiences under their belt. Swiderski, the CCI pediatrician, says he has seen inexperienced nurse practitioners “get thrown into the fire” only to deliver “suboptimal care.”
“There has not been equivalent support for undergraduate or graduate nursing education until now,” writes Jackie Tillett, ND, CNM, FACNM, in a 2011 paper published in the Journal of Perinatal and Neonatal Nursing.
The ACA somewhat rectifies this situation by setting aside money to bolster the clinical experiences of registered nurses and nurse practitioners. The law lifts the cap on grants given to nurses to repay loans if they pursue doctoral degrees, and it also gives financial support to nurses who want to teach at the university level. The National Health Service Corps has also expanded under the ACA, with nurses receiving $50,000 for every two years of service with an at-risk population.
Additionally, the ACA funds demonstration projects at five hospitals throughout the country to train advanced practice nurses. The Centers for Medicare & Medicaid Services (CMS) will reimburse the hospitals to place advanced practice nurses with clinical preceptors in their communities, says Matthew McHugh, PhD, JD, MPH, RN, FAAN, associate director for health outcomes and policy research at the University of Pennsylvania, one of the five sites chosen by CMS.
“It’s important to focus on the substance and quality of the training so that nurses can work in a new and more complex health care system,” says McHugh.
Legislative and political barriers preventing nurse practitioners from fully occupying primary care roles need to be removed, say McHugh and other experts. Only 17 states and the District of Columbia allow nurse practitioners to practice independently without a doctor’s supervision. Reimbursement rates of private insurance and government programs to nurse practitioners and physicians performing the same services also vary greatly, with nurse practitioners usually receiving less money. In 2010, the Institute of Medicine with the Robert Wood Johnson Foundation issued a policy statement urging states to allow nurse practitioners to practice to the full extent of their training, regardless of where they work.
Yet until laws are liberalized across all 50 states, nurse practitioners will have to continue to advocate for their rightful place as primary care providers, even with the ACA as the law of the land.
“There is lot of care that needs to be provided,” says McHugh. “And we need everyone practicing to the top of their abilities to make the most of the workforce that we can.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.