Nurse Led Health Centers

The Future of Nurse Led Health Centers in Low Income Communities

Now is an exciting time for nurses! Although many challenges lie ahead, the momentum for change is palpable. The recent Institute of Medicine: Future of Nursing Report heralds new horizons for nurses. (http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health) The outstanding nursing leadership of members of the KCNPNM is inspiring and has contributed significantly to the progress. Having graduated in 1967 with an Associate Degree in Nursing, from a rural community when the discussions centered on "Why should we stand up when the MD enters the clinical unit?” or "Why do we have to wear the nursing cap?”...the current dialogue is refreshing! Thanks to all of you for your enthusiasm, dedication, perseverance, intelligence and quality!

The purpose of this paper is to highlight the need to include nurse-managed, health clinics (NMHC) that serve low income populations, in the our discussions. Language authorizing a new $50 million grant program for nurse managed primary care and wellness clinics was included in the Patient Protection and Affordable Care Act of 2010, signed into law by the President March 2010. In this law, NMHC was defined as "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” http://www.nncc.us ; http://www.prweb.com/releases/2010/10/prweb4597694.htm

NMHC provide primary health care and health education by nurse practitioners, registered nurses, public health nurses, health educators, mental health professional, community outreach workers, collaborations physicians, and others. They may be based in public housing development, schools, community centers, churches or homeless shelters. The nurse led health centers or clinics serve a diverse population through all age ranges and ethnicities, and a substantial share of the patients are uninsured and/or Medicaid. The National Nursing Center Consortium, Inc. has over 200 members throughout the United States, with 25 of these centers located in the Philadelphia area. http://www.nncc.us

NMHC were highlighted in the Institute of Medicine's Report on the Future of Nursing Report (October 2010). Several recommendations noted the contributions of nurse-managed clinics by calling for establishment of a regulatory and practice environment that facilitates the expansion of nurse-led care. Specifically, the report stated that NMHCs offer opportunities to expand access; provide quality, evidence-based care; and improve outcomes for individuals who may not otherwise receive needed care. It also noted that NMHCs are filling gaps in primary care. The ability to fill gaps in care is particularly important because the nation's primary care workforce is already being overtaxed by the growing demands of an aging population. The demand for primary care is only expected to increase as millions of new patients receive health insurance through health care reform. NMHCs offer high quality, affordable and accessible primary care services to vulnerable populations like seniors and the medically underserved. Nurse-led geriatric services have the potential to lower costs associated with costly chronic conditions and reduce utilization for a population which tends to over utilize primary care.

The difficulties in maintaining NMHC and the fact that many have failed over the years, has discouraged some from choosing this important avenue for improving the nation’s health. This is unfortunate as nurse-led health centers have been shown to improve health and to be a significant part of the safety net care system. Millions of people need, but are not receiving primary care and preventive care, either because they are uninsured, cannot find a primary care provider, or both. The nurse led centers increase access to care and most provide care regardless of the patients’ ability to pay. There is a need to find ways to sustain this important health model, both operationally and financially.

The 2010 Patient Protection and Affordable Care Act healthcare reform legislation is important for two reasons: (a) the new grant program has the potential to become a consistent stream of revenue for the nation's NMHCs that often struggle to cover the cost of offering care to the uninsured and medically underserved ($15 million in grants were awarded through the program in 2010, funding ten clinics) and (b) the legislation marks the first time the term nurse-managed health clinic has been defined in law. Inclusion of the definition of NMHC in the legislation increases their recognition and provides a foundation for future federal policy and advocacy efforts. http://www.whitehouse.gov/healthreform/healthcare-overview

Effective October 22, 2010, the National Committee for Quality Assurance (NCQA) began recognizing nurse-led primary care practices as patient centered medical homes under its Patient Centered Medical Home recognition program. NCQA officials stated that the decision to begin recognizing NMHC as primary care medical homes was prompted by the growing number of states that allow nurse practitioners to serve as primary care providers. A number of states, Maryland, Pennsylvania, and Colorado, have adapted the joint principles of patient centered medical homes to include nurse led practices. This signifies the growing importance of NMHC and it also means that NMHC will be able to receive increased payment incentives associated with primary care medical home status(personal communication from Tine Hansen-Turton on January 30, 2011).

The change strategies currently embraced by the KCNPNM will be helpful. Certainly removing any federal, state, and local policy restrictions will be helpful. Inclusion of representatives of the NMHC in health policy planning will add an important perspective. There is a need to educate our state and local representatives, both returning and new members, about the important work that nurse led health centers do to improve the health of the nations. There is a also a need to make our voices heard in Congress. Encouraging targeted revenue streams to flow to these nurse led centers will help. Many of the "sustainable” nursing centers receive state or local funding to implement the programs, e.g. University of Wisconsin-Milwaukee, the selected nursing centers located in Philadelphia. Recently, some have achieved Federally Qualified Health Center status, e.g. Vanderbilt. The potential to qualify as new access points under the Affordable Care Act is hopeful.

Certainly, firm answers to maintaining NMHC are elusive. However, the nation’s experience with community engaged nurse led health centers has convinced many of the importance of the model to the health of underserved, low income communities. Nurses have the skills, values, and dedication needed to create health equity. But federal, state and local policies followed by funding that will allow them to make this important contribution is critical to their survival. My hope is that this paper will facilitate awareness and encourage members of the KCNPNM to look for ways to advance nurse led health centers during this exciting time of change.

More information about these nursing centers can be obtained from the National Nursing Centers Consortium, Inc. ( www.nncc.us.) The NNCC is a national advocate for policy issues that affect the work of nurse led health centers. The organization provides technical support, works to improve resources to the centers, and provides advice on developing successful applications for selected grant applications. You can find a list of members at the NNCC site. If interested in more information about any particular center, you will find contact information for the programs at the NNCC website.

Kay T. Roberts, EdD, APRN

Executive Director, Harambee Health Center (View a 7 minute Video about Harambee)

Kentucky Director, National Nursing Center Consortium, Inc

http://harambeehealthcenter.org

kay.roberts@louisville.edu

Acknowledgement: A special thanks to Tine Hansen-Turton, Executive Director National Nursing Centers Consortium, for providing selected information for this paper.