Category Archives: Primary care
Have you signed up to receive Sharing Nursing’s Knowledge? The monthly Robert Wood Johnson Foundation (RWJF) e-newsletter will keep you up to date on the work of the foundation’s nursing programs, and the latest news, research, and trends relating to academic progression, leadership, and other essential nursing issues. These are some of the stories in the January issue:
Patients Slowly Gaining Access to Care Provided by Advanced Practice Registered Nurses
In recent years, several states have taken steps to ease restrictions on advanced practice registered nurses (APRNs), indicating that efforts to empower them and improve patient access to care are picking up steam. However, many consumers still lack unfettered access to care provided by APRNs because two-thirds of states do not allow them to practice without physician supervision—and even in states that do, APRNs aren’t always able to practice independently.
Stronger Primary Care System Is Goal of RWJF Scholar
RWJF Executive Nurse Fellow Margaret Flinter, PhD, APRN, has been at the center of three movements: community-oriented primary care, the growth of the community health center movement, and the growth of nurse practitioners as primary care providers. She founded the country’s first formal post-graduate residency training program for new nurse practitioners, and co-directs The Primary Care Team: Learning from Effective Ambulatory Practices, a national project supported by RWJF that is working to help health care organizations develop and accelerate innovations.
Arthur Kellermann, MD, MPH, FACEP, an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars and Health Policy Fellows programs, is dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences. He wrote an article in the November issue of Health Affairs calling for a new class of health care provider—the primary care technician—to improve accessibility to and affordability of primary care.
Human Capital Blog: What is the thrust of your idea?
Arthur Kellermann: We’ve had a decades-long shortage of primary care physicians in this country and, up until now, it has defied solution. One definition of insanity is to continue to do the same thing over and over again and expect a different result. My article suggests a rethinking, and literally a reengineering, of how we deliver primary care in this country. It makes the case for a new class of providers—primary care technicians (PCTs)—who would work remotely, under the online supervision of primary care physicians or nurse practitioners (NPs), to manage stable chronic disease patients, treat minor illnesses and injuries, and provide basic preventive services. These PCTs would make primary care more accessible, more convenient, and more affordable to Americans, wherever they live.
Human Capital News Roundup: Light-based defibrillators, the primary care workforce, how women change men, and more.
Around the country, print, broadcast, and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni, and grantees. Some recent examples:
A strong primary care system is essential to improving health care in the United States, and front-line clinicians, staff, and leaders need to re-examine traditional roles and responsibilities, Maryjoan Ladden, PhD, RN, FAAN, told Medical Home News. Ladden is senior program officer for RWJF’s Human Capital portfolio. To investigate primary care workforce transformation, RWJF funded The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), Ladden said. Her full interview is available at: http://medicalhomenews.com/ (subscription required.)
Women with post-traumatic stress disorder (PTSD) gain weight more rapidly and are more likely to be overweight or obese than other women, according to a study co-authored by RWJF Health & Society Scholars alumna Magdalena Cerda, DrPH. The study, featured in Health Canal, is the first to look at the relationship between PTSD and obesity over time.
New tools such as the Omnibus Risk Estimator, which the American Heart Association recommends doctors use instead of cholesterol tests to determine whether to prescribe statins, are developed with little regulatory authority over their design and use, Jason Karlawish, MD, writes in a New York Times op-ed. Karlawish, recipient of an RWJF Investigator Award in Health Policy Research, encourages better oversight and regulations to monitor such tools.
Michael Hochman, MD, MPH, is medical director for Innovation at AltaMed Health Services, a 43-site federally qualified health center in Southern California. He completed the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at the University of California, Los Angeles, and the U.S. Department of Veterans Affairs in 2012. While a Clinical Scholar, Hochman co-led a primary care demonstration that was published last month in JAMA Internal Medicine. He recently published, 50 Studies Every Doctor Should Know.
Primary care in the United States is at a crossroads. As health care becomes increasingly disjointed and costs continue to rise, primary care providers face increasing pressure to take charge of the health system. Indeed, we know that health care systems with more developed primary care infrastructures are more efficient and of higher quality than those with a weaker primary care foundation.
But at the same time, more and more health care professionals are shying away from careers in primary care. Not only is the work challenging (late-night phone calls, numerous tests and studies to follow up on, ever-increasing regulatory requirements), but the pay is lower than in other fields of medicine.
Maryjoan Ladden, PhD, RN, FAAN, is a senior program officer at the Robert Wood Johnson Foundation.
During a recent visit to my adopted home state of Massachusetts, I took a fresh look at a primary care practice I had previously known only from afar. I was part of the team visiting Cambridge Health Alliance–Union Square Family Health, which is one of 30 primary care practices recognized as exemplar models for workforce innovation by The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP) project. This project, a new initiative of the Robert Wood Johnson Foundation and the MacColl Center at Group Health Research Institute, is studying these 30 practice sites to identify new strategies in workforce development and interprofessional collaboration. The overarching goal of LEAP is to better understand the innovative models that make primary care more efficient, effective, and satisfying to both patients and providers, and ultimately lead to improved patient outcomes.
This site visit took me back to my time as a nurse practitioner at Boston Medical Center, Harvard Vanguard Medical Associates, and Boston’s school-based health centers. This is where my passion for primary care began. As we prepare for millions more Americans to enter the health care system in the coming year, we must identify ways to expand access to primary care, improve the quality of care, and control costs. One important way is by exploring how to optimize the varied and expansive skill sets of all members of the primary care team. This idea has been examined in medical and popular media, but there has been little study of the workforce innovations employed by primary care practices to meet the increasing demands for health care.
For years, medical students have been choosing specialties over primary care at a rate that has alarmed experts concerned about a shortage of primary care providers. Two new surveys shed light on the primary care workforce.
Primary care physicians were the most actively recruited professionals within the physician and advanced practitioner recruiting market by the health care staffing firm Merritt Hawkins & Associates from April 1, 2012 to March 31, 2013. Merritt Hawkins recently released a report summarizing the trends among its 3,097 recruiting assignments in 48 states conducted during that time period. For the seventh consecutive year, family physicians and general internists were the top two most requested physicians, the report says.
The firm also notes a rise in demand for physician assistants and nurse practitioners, as well as an acute shortage of psychiatrists.
In addition to being in high demand, another survey from the Hays Group, a global management consulting firm, finds primary care physicians could see a higher salary increase than specialists in 2014. The growth will be even greater for primary care physicians in hospital-based settings, the report says.
This is part of the September 2013 issue of Sharing Nursing's Knowledge.
More New Nurse Practitioners Heading to Primary Care
Two recent analyses of workforce data offer new insights into the role nurse practitioners (NPs) are likely to play in combating the coming shortage of primary care providers in the U.S.
The first analysis, commissioned by the Agency for Healthcare Research and Quality (AHRQ) and released in August, finds that slightly more than half the nation’s nurse practitioners are practicing primary care. In all, 55,625 of the nation’s 106,073 nurse practitioners are in primary care, according to data drawn from the Centers for Medicare and Medicaid Services’ National Provider Identifier database.
At the same time, an analysis of graduation trends conducted by Robert Wood Johnson Foundation Executive Nurse Fellow alumna Debra Barksdale, PhD, RN, FAAN, and colleagues, finds that graduation rates for NPs suggest more help is on the way. According to Barksdale’s reading of data from the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties, 84 percent of NP graduates in 2012 were prepared in primary care. That represents an eye-catching 18.6 percent increase from 2011 to 2012.
Italo M. Brown, MPH, is a rising third-year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social & behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. Read all the blog posts in this series.
In 1986, Congress took a step in the direction of patient advocacy by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA). One part of this act, the Emergency Medical Treatment and Labor Act (EMTALA), has served as the precedent for federally mandated care and has largely shaped our understanding of urgent care delivery in America. While some have touted EMTALA as a public health victory, many have scrutinized the federal mandate, citing its imperfection and labeling it as a strong contributor to the current ailments of our emergency medical system.
However, 27 years after EMTALA became law, a greater emphasis is placed on preventive measures and comprehensive care, rather than urgent care, as a means to reduce negative health outcomes. Naturally, champions of cost-efficient comprehensive care have suggested that a federal mandate should be explored.
Kori Sauser, MD, is an emergency medicine physician and a Robert Wood Johnson Foundation (RWJF)/U.S Department of Veterans Affairs Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Sauser and her coauthors, both affiliated with the RWJF Clinical Scholars program, to respond. Sauser’s response follows. Read all the blog posts in this series.
I am struck by the fact that we are still discussing whether health care is a right or a privilege, because it has been long-determined that the medical care that I provide is a right. As an emergency physician, I am held to the standards of the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that I provide basic, stabilizing treatment to all who present to the emergency department (ED), regardless of ability to pay.
So when a patient presents to the ED when I am working a shift, I take care of the patient appropriately and without a thought to their payment status. When “Juan,” a young Mexican day laborer without insurance presents with an advanced toe infection as a consequence of his undiagnosed diabetes, I am able to start his diagnostic work-up and treatment, and to admit him to the hospital for continued antibiotics and definitive care of the toe.
Katherine Vickery, MD, is a family medicine resident and a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Vickery and her coauthors, both affiliated with the RWJF Clinical Scholars program, as well as others from RWJF programs to respond to the question. Vickery’s response follows. Read all the blog posts in this series.
Before I joined the Robert Wood Johnson Foundation’s Clinical Scholars program, I trained in family medicine at a federally-qualified, or community health center, United Family Medicine, in St. Paul, Minn.
Many of my patients, and the struggles they faced in trying to access health care, motivate the work I’m doing as a scholar. At the top of this list is “Juan,” a 35-year-old Mexican man working as a day laborer to support his family.
I became Juan’s doctor after a hospitalization where his toe was amputated due to advanced infection resulting from his undiagnosed type II diabetes. He had no insurance and had not seen a doctor in years. The preventability of Juan’s amputation and treatability of his disease was always a frustration to me, and I began to wonder, “What kind of backwards system do we have that ensures a man’s access to a costly hospitalization to remove his toe but bars him from the primary care which can prevent or diagnose and easily treat his disease?”