Q&A: New Health Clinics for a Changing World

WASHINGTON, Sept. 13 -- Recently, the U.S. Department of Health and Human Services announced $15 million in funding for nurse-managed health clinics. These new clinics provide a new approach to a growing vulnerable population that requires new attention due to ever-increasing chronic conditions. 

Tine Hansen-Turton has over 15 years of experience in providing executive management and has led a national movement of nurse-managed health centers for the past decade. Under Hansen-Turton's leadership, the National Nursing Centers Consortium, a professional association of nurse-managed community-based health centers, has grown from 11 regional health centers to over 200 centers serving more than 2 million vulnerable people. 

TNS: Tell me about how your background relates to nurse managed clinics. 

HANSEN-TURTON: Before I came to the National Nursing Centers Consortium, my background was in public housing. There were (and still are) a number of wonderful nurse-managed health clinics in Philadelphia located in public housing developments, which I helped start. I saw early on how effective these nurse-led practices were, how great their patients outcomes were for a very vulnerable population, and how trusted they were by the community. I saw that they were an innovation that had an incredible amount of potential for this country. 

TNS: How is a nurse managed health care clinic different from one managed by MDs? 

HANSEN-TURTON: In nurse-managed health clinics, advance practice nurses (primarily nurse practitioners) are the primary providers of care. While physicians provide collaborative services as needed clinically or required by various state laws, they do not control the operation of the health clinics. 

The nurse-managed health clinics tend to provide much more comprehensive care, including integrated primary care, behavioral health and chronic disease management and patient education. Disease prevention through education is also a key aspect of the model. 

In addition to providing services directly to clients, nurse-managed health clinics also play an important role in nursing education. Most are affiliated with academic schools of nursing and serve as clinical education and practice sites for nursing students and faculty. 

More than 85 of the nation's top nursing schools have nurse-managed health clinics that provide high-quality, care to patients and enhance learning opportunities for students and faculty, including Texas Tech University, the University of Alabama, the University of California-San Francisco, the University of Pennsylvania, the University of Illinois-Chicago, and Vanderbilt University (among many others). 

TNS: How are nurse practitioners being used and is this a shift from "traditional" care delivery? 

HANSEN-TURTON: In nurse-managed health clinics, care is provided by an interdisciplinary team of health professionals, including nurse practitioners, clinical nurse specialists, registered nurses, midwives, health educators, community outreach workers, health care students and collaborating physicians. These providers really take a comprehensive view of patient health and try to address the root causes of health problems, not just the symptoms. 

TNS: What are the roles of a nurse practitioner in the workplace? 

HANSEN-TURTON: More and more employers are recognizing the value of providing on-site health care services, and nurse practitioners are great providers for on-site clinics. For example, Project Salud in Kennett Square, Pennsylvania - a nurse-managed health clinic that serves a high percentage of Latinos who work on nearby mushroom farms - has opened a number of satellite sites located on local farms. 

Project Salud nurses offer primary care services, including health and behavioral health screening, physical examinations, episodic care for illness and injury, ongoing care for chronic diseases, and health and social service referrals. They also offer health education (primarily on tobacco cessation, fitness and stress reduction/behavioral health) and health coaching services. 

TNS: How cost effective is the implementation of nurse practitioners to relieve doctor workloads? 

HANSEN-TURTON: Nurse practitioners provide cost-effective care with similar patient outcomes to physicians. An analysis in Health Affairs in 2008 of NP-staffed convenient care clinics found cost savings of at least $50 per episode compared to other health care settings. 

Nurse-managed health clinic patients have been found to have higher rates of generic medication fills and lower rates of hospitalization and emergency room utilization compared to other safety net providers. 

TNS: What are some of the barriers that nurse-managed health clinics face? 

HANSEN-TURTON: Because most nurse-managed health clinics are operated by schools of nursing, they can't meet the community governance requirements of the Federally Qualified Health Center (FQHC) program (most nurse-managed health clinics are legally controlled by their parent university's Board of Directors). The federal government makes available to FQHCs a broad array of services and funding that really promote sustainability. 

When nurse-managed health clinics don't have access to these services, it makes it harder for them to serve uninsured patients while remaining fiscally stable. Also, regulation of nurse practitioner practice has changed a lot over the past decade, but some health care policies haven't caught up. 

Nurse-managed health clinics have to contend with outdated policies that don't match the current ability of nurse practitioners to provide primary care. For example, many insurers don't recognize or reimburse nurse practitioners as primary care providers. 

Another current policy challenge is whether nurse-led practices will be officially recognized as medical homes. (The medical home is a team-based primary care model designed to improve patient outcomes.) 

While nurse-led practices are very well-suited to serve as medical homes, NCQA (the National Committee for Quality Assurance) does not recognize nurse-led practices as medical homes. When nurse practitioners are excluded from medical home programs, nurse-managed health clinics can't access existing and future funding and reimbursement. 

TNS: Why is it important that nurse practitioners be considered primary care providers by insurance? 

HANSEN-TURTON: Nurse practitioners and other advanced practice nurses in nurse-managed health clinics act as primary care providers for hundreds of thousands of low-income, vulnerable and under-served patients. These clinics primarily focus on providing care to the uninsured, and they use a sliding scale to collect payment from uninsured patients. 

The amount collected does not come close to covering the actual cost of caring for the uninsured. This situation is exacerbated by managed care policies that don't recognize nurse practitioners who act as primary care providers. Because nurse-managed health clinics serve a high percentage of uninsured patients, it is especially important that they reimbursed fairly for the care that they provide to managed care enrollees. 

TNS: How will the Affordable Care Act assist in this implementation? 

HANSEN-TURTON: Just last month, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced new federal investments in innovative, community-based practices led by nurse practitioners. Presented as part of a comprehensive primary care workforce development strategy and made possible by the Affordable Care Act, this new funding initiative will invest $15 million in nurse-managed health clinics. 

In addition, there are a variety of new funding opportunities in the Affordable Care Act that focus on public health, wellness and disease prevention. Because nurse-managed health clinics offer such a broad array of health promotion services to their patients, this funding will help nurse-managed health clinics expand their outreach and health education activities. 

TNS: What are some of the nurse managed clinics that have been implemented in Philadelphia? 

HANSEN-TURTON: Philadelphia has more nurse-managed health clinics than any other city in the country. We have been very fortunate to have a local foundation, Independence Foundation, which the last decade has invested in nurse-managed clinic in the region. Many of the nurse-led centers in Philadelphia have been nationally recognized for their outstanding work. 

Some of our Philadelphia-area members include the PHMC network of health centers, the Family Practice & Counseling Network, and 11th Street Family Health Services of Drexel University. 

TNS: How prevalent are nurse managed health care clinics in the US? 

HANSEN-TURTON: Nurse-managed health clinics provide high-quality care to low-income and vulnerable patients in diverse communities in over 40 states throughout the country. Currently over 250 nurse-managed health clinics operate throughout the United States. They record over 2.5 million annual client encounters and provide primary care to approximately a quarter of a million patients in rural, urban, and suburban communities throughout the nation. 

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Zaher Karp is a freelance writer based in Madison, Wis.