Nancy L. Rothman, EdD, RN Consultant/PHMC Nursing Network

1. Nurse-Managed Clinics and Strategies for Enhancing Workforce Development in the States The National Academy for State Health Policy State Health Policy Conference - October 2011 Nancy L. Rothman, EdD, RN Consultant/PHMC Nursing Network Independence Foundation Professor of Urban Community Nursing Dept. of Nursing, CHP and SW, Temple University Rothman 1

2. Today’s Presentation • A broad overview of Nurse-Managed Health Clinics (NMHC) • The current role of NMHCs in workforce development • Why expanding the role of NMHCs is critical to the success of state workforce development and health care reform efforts. • Massachusetts Case Study • Pennsylvania Case Study • Discuss some of the challenges facing NMHCs and strategies for supporting the nurse-managed model. Rothman 2

3. What is a Nurse-managed Health Clinic (NMHC)? A nurse managed health clinic is a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency. Source: Affordable Care Act (ACA) Characteristics: NMHCs are accessible service sites that deliver community-based primary and/or wellness care regardless of a patient’s ability to pay. The majority of care is provided by nurses—a team of advanced practice nurses (Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives), RNs and other health professionals (e.g. Social Workers, Nutritionists) in collaboration with MDs in jurisdictions where required. Dominant theme: Nurses control their own practice and provide the care. Rothman 3

4. Nurse-Managed Health Centers Generally • Currently over 250nurse-managed health centers operate throughout the United States, serving diverse communities in urban, rural, and suburban locations. Source: NNCC Member Survey, 2008 Rothman 4

5. Services Provided • The majority of patients are on Medicaid or uninsured. • They receive: • Primary Care • Mental/Behavioral Health • Family Planning • Prenatal Services • Disease Prevention • Health Promotion Rothman 5

6. MOST COMMON NMHCDIAGNOSES/REASONS FOR VISITS Hypertension Depression Diabetes Child Health Exam Hyperlipidemia Adult Health Maintenance Exam Obesity Upper Respiratory Infection Asthma Normal pregnancy Rothman 6

7. NMHCs and Workforce Development According to national data from the Institute for Nursing Centers, over 90 schools of nursing operate NMHCs. All together there are approximately 184 academically-run NMHCs in the U.S.A. Benefits: NMHCs provide clinical placements for undergraduate and graduate nursing students necessary to increase enrollment in nursing education programs – helping to eliminate shortages in supply of nurses. NMHCs provide primary health care experience with underserved populations. This exposure enhances the chance that the students will select to practice in underserved areas. NMHCs give students the unique opportunity to integrate classroom learning with community-based care. Rothman 7

8. What Students Say About NMHCs • The community-based experiences were not found in other clinical rotations. • Patient populations were diverse. • Health disparities were visible. • NMHCs were ideal settings to teach business and financial concepts. • Nursing practice is consistent with conceptual models of nursing presented in the classroom. Rothman 8

9. Why Including NMHCs in Workforce Development Effort is Important to State Health Care Reform… Rothman 9

10. State Case Studies: MA and PA • Massachusetts invested in insurance access before ensuring it had the infrastructure to handle increased demand for services. • In Pennsylvania, Governor Rendell invested in health care infrastructure first, setting the stage for insurance reforms in the future Rothman 10

11. MA Reform Overlooked Workforce Development • Since 2006, Massachusetts has gone from having as many as 650,000 uninsured residents to having 167,300 today (the lowest rate of uninsured residents in the nation). • But, the State was not prepared for the influx in newly insured residents. • Primary physicians were quickly overwhelmed. • In order to meet increased demand, in 2008, the state enacted a law increasing utilization of NMHCs, nurse practitioners and other non-physician providers. Rothman 11

12. PA Reform: Legislative Change PA Reform called for approximately 49 statutory/regulatory changes to allow NPs to practice to the full extent of their scope of practice. NPs in PA can now: • Make respiratory and occupational therapy referrals • Perform disability assessments for the program providing Temporary Assistance to Needy Families (TANF) • Issue homebound schooling certifications • Perform and sign the initial assessment of methadone treatment evaluations Order home health and hospice care Order durable medical equipment Issue oral orders to the extent permitted by the state’s health care facilities Make physical therapy and dietitian referrals Rothman 12

13. PA Reform: Inclusion of NMHCs in PCMH Projects In 2008, the Governor’s Office of Health Care Reform, along with physicians, nurses, and insurers, successfully began the implementation of Wagner’s Chronic Care Model in selected primary care practices in Southeastern PA. Eight of the initial 32 practices were nurse-led. In 2010, the initiative was expanded through out the state and now includes 151 participating practices. Outcomes are extremely positive - 2009 data shows that participating diabetics are 33% more likely to have control of their blood sugars, 40% more likely to have control of cholesterol levels and 25% more likely to have normal blood pressures when compared to non-participating diabetics. Rothman 13

14. Strategies for Fully Utilizing NMHCs • IOM’s Future Nursing Report Message: • Nurses should practice to the full extent of their education and training. (Requires scope of practice reform) • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. (Requires promulgating NMHCs and providing access to students for clinical sites) • Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States. (Requires including NMHCs in ACOs and state insurance exchanges) • Effective workforce planning and policy-making with better data collection and information infrastructure. (Requires promoting NMHC participation in Patient Centered Medical Home projects, as NCQA did in October, 2010) Rothman 14

15. Remaining Challenges • Securing Participation in Medical Home Projects - Many Medical Home documents and demonstration projects still contain physician centered language which prohibit NMHC participation i.e. AAFP’s Joint Principles for the Patient Centered Medical Home. • Securing Participation in Accordable Care Organizations –The draft ACO regulations contain physician centered language which will make NMHC participation difficult. • Securing Participation in Managed Care- 48% of all major managed care organizations do NOT credential nurse practitioners as primary care providers. • Securing Federal Funding- The ACA created a new grant program for NMHCs which received $15 million from the Public Health Prevention Fund in 2010. But deficit reduction efforts are putting the future of the program in jeopardy. Rothman 15

16. For More Information Nancy L. Rothman Email: rothman@temple.edu Phone: 215-707-5436 Rothman 16