Kelly’s personal interest in the field of health care and nursing: Relate hearing stories from mother (a nurse) when she was growing up.
Throughout the years the challenge of creating a viable health care initiative has been of great concern for citizens, politicians, and health care providers. With recent developments, such as the Affordable Care Act (aka ‘Obama-Care’), the strategies being considered to reform health care for Americans continues to be of primary importance throughout much of society’s current conversation.
Looking back at earlier attempts to forge a working health care policy, Hillary Clinton’s efforts toward managed care come to mind. A few of Mrs. Clinton’s notable issues included questions that are of growing importance today: a better health care system for the chronically ill, cost-saving through electronic medical record keeping, and the notion that rather than a single-payer system, health care should shift to ‘managed competition.’
Hillary Clinton was noted for emphasizing the importance of the ‘village’ in accomplishing some of our larger challenges and goals. With respect to health care, it is perhaps more accurate to say that rather than a village, it takes a medical home’ run by a nurse practitioner’ to make comprehensive health care work in an efficient and cost effective manner.
Defining the Medical Home Model
There are four components that comprise the Patient-Centered Medical Home (PCMH):
1) Fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership;
2) New ways of organizing practice;
3) Development of practices’ internal capabilities; and
4) Related health care system and reimbursement changes.
The intended goal of the PCMH is improving the health of individuals, communities, and populations. Additionally, the Medical Home serves to increase the value of healthcare.
The driving principle is that PCPs (NPs ‘or physicians’) are the obvious nexus from which the quality of health care can be improved.
Managing Complex Patients
Providing quality care for patients that have chronic health conditions and other complex needs has arguably been a challenge for many primary care practices. Fee-for-service practices may find that they are unable to offer the best coverage for this patient population. The strategy at the foundation of the Medical Home focuses on overcoming and eliminating barriers so that patients with complex medical needs will get the quality, comprehensive, and accessible care that may be essential for the well-being of this patient population. Patients who are frail, disabled, and elderly often have to use multiple settings in order to receive adequate care. It is not surprising that their increased use of health care services may become somewhat fragmented, allow things to get lost in the shuffle, and result in less than quality care.
The patient-centered medical home model of care focuses on providing health care services that are cost-effective, high-quality, and personalized, based on the coordination of a primary care provider. According to the U.S. Department of Health and Human Services, The Affordable Care Act supports patient-centered medical homes in health centers. ‘The patient-centered medical home delivery model is designed to improve quality of care through team-based coordination of care, treating the many needs of the patient at once, increasing access to care, and empowering the patient to be a partner in their own care’ (2014). The ACA, popularly known as Obamacare, provides an unprecedented opportunity to strengthen primary care and spread the medical home.
‘ Collaborative Care:
With health care being organized across various components of the health care system, patient history is carefully documented across institutions and providers. This adds the potential of better management for patients with complex needs. It also serves as a means of prevention in ordering duplicate tests and procedures.
‘ Care Plan:
Preparing and maintaining patient care plans serve to monitor the needs, concerns, goals, and progress of patients with complex needs. Medical and social information, impact on patient’s well-being, and means of helping patients achieve their desired health care outcomes benefits both patients and care providers.
‘ Supporting material & patient examples:
In 2013, Jackson et al published the following in the Annals of Internal Medicine, ‘The PCMH model is being widely implemented in various health care systems and includes key principles that are encouraged in the Affordable Care Act’ This review indicated that PCMH is a conceptually sound approach to organizing patient care and appears to hold promise, especially for improving the experiences of patients and staff involved in the health care system’ (Jackson et al, 2013).
With respect to cost outcomes from PCMH interventions, a sample of specific medical homes reported the following:
‘ Community Care of North Carolina: 40% decrease in hospitalizations for asthma and 16% lower ER visit rate; total savings to the Medicaid and SCHIP programs are calculated to be $135 million for TANF-linked populations and $400 million for the aged, blind, and disabled population.
‘ Genesse Health Plan HealthWorks PCMH Model: 50% decrease in ER visits and 15% fewer inpatient hospitalizations, with total hospital days per 1,000 enrolees now cited as 26% lower than competitors.
‘ Johns Hopkins Guided Care PCMH Model: 24% reduction in total hospital inpatient days, 15% fewer ER visits, 37% decrease in skilled nursing facility days. Annual net Medicare savings of $1,364 per patient and $75,000 per Guided Care nurse deployed in a practice
(Grumbach, Bodenheimer, and Grundy, 2009).
NPs are serving as the thought leaders in today’s medical care; they are already doing the work; the PCMH is one of the first steps in realizing the benefits/rewards of that work.
‘ Potential benefit to patients:
In addition to better coordination and quality of health care services, as well as more involvement in and accountability for their care, health care reform bolsters primary care by offering patient incentives to obtain preventive care. An annual wellness visit, like an adult checkup, will be covered; also, under the law, other additional expenses related to most preventive care will no longer be allowed. In summary, patients will have easier access to supportive health services, experience improved care, be supported toward healthy behaviors, and ultimately have better outcomes based on their care.
‘ Advantages of Medical Home to Nurse Practitioners:
Increase in fee schedule across the board. For medical homes to live up to their potential, health insurers will need to rethink how they pay and how much they pay for primary care. Indeed, payment reform is a significant aspect of the medical home model. The approach that is now used and has been used for some time is one that is a fee-for- service model, which may often lead to unnecessary services. Using the medical home model, however, the practices potentially may gain a bonus or enhanced payment, which is often associated with value, such as a higher quality of care. Practitioners are likely to see additional yearly income, and may also enjoy increased job satisfaction as well. In summary, practices enjoy access to community networks, better transition of care, decrease in treatment disparities, better use of preventive services, and increased patient satisfaction.
‘ No ER:
With better access to improved services, Emergency Rooms will no longer have to serve as primary care substitutes for patients. Additionally, patients will be more likely to seek care sooner because they have access to what they need, rather than delaying care. Moreover, the growing use of community services that support prevention can help to reduce patient re-hospitalization.
Current Policy Barriers
1) State Licensing and Regulations:
In order to fully realize and implement the potential of NP-run Medical Homes, certain policy issues have continued to limit and delay the progress that is so desperately needed. Despite the Institute of Medicine’s 2011 report, The Future of Nursing: Leading Change Advancing Health, ‘Advanced practice registered nurses (APRNs) should be able to practice to the fullest extent of their education and training’ (IOM, 2011). The glitch, however, is the reality that many state licensing bodies, which regulate NP practice, have not caught up with the need and the significance of eliminating obstacles that would allow NPs to practice to the fullest extent of their abilities, training, and expertise. Indeed, approximately only one-third of the nation has laws that cover full practice authority for NPs (Hain & Fleck, 2014). The barriers are imposed in one of two ways:
‘ NPs are regulated by means of a collaborative agreement with an ‘outside health discipline’ in order to provide in patient care.
‘ NPs can only provide patient care under supervision, delegation, or team-management by an ‘outside health discipline’ (Hain & Fleck, 2014).
2) Physician Resistance and Opposition:
We have all heard the reports and claims that the U.S. is experiencing an increasing shortage of primary health care providers. Writing for Policy Matters Journal, Brown notes, ‘Medical students have strong disincentives to become Primary Care Physicians, including comparatively low pay, high levels of medical school debt, and the danger of medical malpractice suits’ (Brown, 2014). There is no reason to believe that the need for primary care health care providers is going to do anything other than escalate. The most obvious and readily available solution for the demand of primary care providers is clearly the role that NPs are already filling, and have been for some time.
However, Brown further notes that this solution is repeatedly hampered by resistance froms physician groups. Brown writes, ‘The underutilization of nurse practitioners is largely attributable to legislative opposition from powerful political organizations and their associated lobbyists. Physicians organizations, including the American Medical Association, are reluctant to relinquish responsibilities, primarily for fear of losing wages to NPs’ (2014). This creates a need on the part of the physicians groups to ‘have it both ways,’ i.e., they do not want to be the remedy to the problem, nor do they want NPs to be the solution. This kind of resistance and obstinance serves to create unnecessary gridlock when it comes to quality patient care.
3) Reimbursement Policies:
Insurance companies hold a great deal of control over health care issues, which subsequently has a significant impact on both patients and health care providers. This is clearly the case with Nurse Practitioners and their ability to receive equitable reimbursement for the medical care they provide to their patients. Insurance companies have that degree of control because, for the most part, their policies are linked to state licensing and regulations. What this boils down to is a basic truth: ‘Nurse practitioners historically receive lower wages and reimbursement fees as compared to their physician counterparts. These lower payments make it difficult for NPs to financially sustain a primary care practice’ (Chapman, Wides, & Spetz, 2010).
NPs are on the cutting edge and have the opportunity to set the example of how medical care should be provided. The changes that we seek are not going to come without stepping forward in terms of advocacy, leadership roles, and taking an active role in how health care policy is shaped and changed in the United States.
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