Stronger Primary Care System Is Goal of RWJF Scholar

    • January 13, 2014

Problem: The shortage of primary care providers is likely to become more acute as both the population of patients and of primary care providers ages and as millions more people enter the health care system under the Affordable Care Act. Across the country, innovative primary care practices are testing and implementing team-based innovations to increase the effectiveness, efficiency, and satisfaction of providers and patients alike, but “best practices” have yet to be identified and widely adopted.

Background: Margaret Flinter became a family nurse practitioner shortly after the role was first developed and has since risen to the top of the field as a leader of a world class community-based health care clinic that provides comprehensive primary care services.

After earning her bachelor’s degree in nursing at the University of Connecticut in the 1970s, Flinter, PhD, APRN, held a variety of clinical nursing positions in public health in rural Connecticut and Georgia, and in critical care. But an article she had read while an undergraduate about this “new, expanded role for nursing in the community called the nurse practitioner” remained with her. Donna Diers, then the dean of the Yale School of Nursing, had called on the school to radically transform the U.S. health care system—writings that convinced Flinter that Yale, and the role of nurse practitioner, were her destination.

Flinter enrolled in a master’s-level program in community health, with a family nurse practitioner clinical track at Yale University in 1980, and earned a National Health Service Corps Scholar award. In return, she accepted an assignment to what was then a small storefront clinic—the Community Health Center (CHC), Inc., in Middletown, Conn.—joining a small staff with a fierce conviction that health care is a right, not a privilege.

As the center’s first nurse practitioner, Flinter found herself 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, particularly in underserved communities. “I was on the cutting edge,” she quips, “but not the bleeding edge.”

Today, those movements are now part of the essential infrastructure of the U.S. health care system, and Flinter is at the epicenter of the transformation of primary care as senior vice president and clinical director of the CHC. She is also founder of the country’s first formal post-graduate residency training program for new nurse practitioners (a program she developed while a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow between 2002 and 2005). And she co-directs The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP), a national project supported by RWJF.

The community health center she joined in 1980 today is a premier, state-wide primary care system serving 130,000 patients in a wide range of settings, from primary care centers to schools to homeless shelters. It remains committed to its core mission: providing comprehensive primary care services in medicine, dentistry, and behavioral health to people in need. It has also become a model of research and innovation in community health and primary care. It is home to the Weitzman Center for Innovation in Community Health and Primary Care, as well as the new Weitzman Quality Institute, which is conducting pioneering work in quality improvement in primary care.  The center has advanced innovations from “eConsults,” to fully integrated behavioral health in primary care, to redefining the role of nurses in primary care.

Increasingly, Flinter and the center have turned attention to working on issues of reform and transformation at the community, state, and national levels.

Solution: Now, Flinter is working to help other health care organizations develop and accelerate their innovations.  RWJF invited her, as part of her work at CHC. to assume the role of co-director with Ed Wagner, MD, MPH, MAPC,  of the PCT-LEAP project, which is studying innovations in primary care that increase effectiveness, access, outcomes, and provider and consumer satisfaction with primary care. It is a joint effort of RWJF and the MacColl Center for Health Care Innovation at Group Health Research Institute and includes a national advisory committee and researchers.

The primary care teams that are emerging as exemplars of effective practice recognize that no one person can accomplish all primary care goals. Primary care providers, whether physicians, nurse practitioners, or physician assistants, must work hand-in-hand with medical assistants, nurses, behavioral health specialists, health coaches, pharmacists, and other team members who each make important contributions to meeting the health care needs of all patients on the primary care provider’s panel. This is the solution to ensuring that each patient gets the attention he or she needs for prevention and routine care as well as for acute and complex chronic care—and that primary care practices can absorb the demand for care without burn-out or compromise

“We are seeing such progress in many areas,” Flinter said, “and what was an innovation a few years ago is now often an ingrained “best practice” in these sites. Medical assistants have stepped up as essential team members, ensuring that patients routinely get the benefit of screening, prevention, and education and coaching in self-management goals.”

Primary care nurses are engaged in complex care management, coordination, and independent nursing visits to ensure that patients with chronic illness are setting and achieving their clinical goals, Flinter said. Behavioral health specialists have moved from external referrals to fully integrated team members. Pharmacists are engaged in medication management, advising primary care providers, and educating patients. Health coaches are ensuring that patients are empowered with knowledge and “actionable” data.  

And the heart of primary care—the relationship between these team members and the patient and family—is fully at the center of this team-based care. The question at the core of the PCT-LEAP project is: “How do we maximize the ability of every member of the primary care team, and the team as a whole, to contribute to the care of individual patients and the practice as a whole?”

To find the answer, the PCT-LEAP team, including its research specialists, evaluated primary care teams at 300 health care practices around the country over the past two years and used the findings to narrow the list down to 31 “practice exemplars” in rural and urban settings, ranging from private practices to community health centers to academic medical practices.

Teams of three individuals representing clinical experts, qualitative researchers, and consumer and patient specialists studied the practices during intensive on-site visits. “We were really trying to understand what was innovative about how they approached the workforce, how the practice had developed and how they were sustaining innovations, and the impact that had on their quality and outcomes,” Flinter said. “And we were doing that with an eye toward creating new resources for primary care practices across the country that are ready to adopt these innovations so that they don’t have to start from the ground up. Nobody should have to re-invent the wheel. We don’t have time, and so much substantial work has already been done by these practice exemplars.”

In October, 2013, the PCT-LEAP project hit a milestone when it brought together more than 100 people from the 31 selected practices to participate in an intensive “learning community” characterized by intensive discussion of the essential elements of each innovation, yet-unanswered questions, and strategies for advancing the knowledge in the field.

Flinter’s hope is that the exemplar practice members of this “learning community” will become a “force multiplier” in advancing primary care as they share their advanced knowledge of primary care teams and workforce innovations with others.

That, she says, will ultimately lead to a health care system that is more patient-centered, has better outcomes, with greater satisfaction for providers and patients alike. Last but not least, revitalizing primary care will ultimately contribute to national efforts to train, recruit, and retain the best and the brightest physicians, nurse practitioners, and other health professionals into the domain of primary care, where they are urgently needed.

RWJF Perspective:  The nation’s largest philanthropy devoted exclusively to health and health care, RWJF has invested heavily in efforts to improve access to health care, increase its quality, and reduce its cost. Building a strong and effective primary care workforce is a key way to meet these goals. The Primary Care Team: Learning from Effective Ambulatory Practices will identify best practices at effective primary care practices across the country and create a toolkit to facilitate the adoption of best practices.

Margaret Flinter, PhD, APRN

Margaret Flinter, PhD, APRN