The waiting room at Glide Health Services — a nurse-managed clinic serving homeless and low-income patients — seems worlds away from the littered streets and grimy brick buildings of San Francisco’s Tenderloin neighborhood just outside its windows. The room is brightly lit. Floors are polished wood. Waiting clients watch a basketball game on a wide-screen television, and staff members pull up electronic records on new computers.
Even more state-of-the-art than the recently remodeled waiting room is the primary care provided in the clinic’s seven exam rooms, four behavioral health rooms, classrooms and exercise spaces. Patient care encompasses wellness, prevention, chronic disease management and behavioral health services, delivered by a team including nurse practitioners, a diabetes nurse specialist, mental health professionals, social workers and students from a variety of healthcare professions.
Like most of the 250 other nurse-managed health centers in the country — including 10 recipients of funds through the 2010 Affordable Care Act — Glide exemplifies what policy experts say must be the new model of U.S. healthcare if it is to stay affordable: integrated care, disease management, prevention and wellness, interdisciplinary teamwork and patient-centered care. "We really practice what everybody preaches," said Tine Hansen-Turton, MGA, JD, CEO of the National Nursing Centers Consortium in Philadelphia. Despite their successes, nurse-managed clinics struggle for funding. Many insurance companies don’t fully reimburse for primary care provided by NPs, Hansen-Turton said, and many of the centers’ patients are uninsured, forcing the clinics to compete for a shrinking pool of government and private grants.
The constant scramble for funding could be eased considerably after full implementation of the Affordable Care Act in 2014, Hansen-Turton said. The ACA would increase healthcare coverage to the poor and uninsured through Medicaid expansion, insurance subsidies and state-run health insurance exchanges, creating more reimbursement possibilities for providers who care for uninsured people — the bulk of community clinics’ patient populations. The U.S. Supreme Court is considering whether to overturn some or part of the ACA, including provisions for insurance exchanges and Medicaid expansion. A ruling is expected by late June.
Reimbursement by third-party payer, whether public or private, "is the best lifeline for sustainability of these clinics," said Julie Sochalski, RN, PhD, FAAN, director of the Division of Nursing in the Bureau of Health Professions at the U.S. Health Resources and Services Administration, which allocates funds for nurse-managed health centers.
Even more state-of-the-art than the recently remodeled waiting room is the primary care provided in the clinic’s seven exam rooms, four behavioral health rooms, classrooms and exercise spaces. Patient care encompasses wellness, prevention, chronic disease management and behavioral health services, delivered by a team including nurse practitioners, a diabetes nurse specialist, mental health professionals, social workers and students from a variety of healthcare professions.
Like most of the 250 other nurse-managed health centers in the country — including 10 recipients of funds through the 2010 Affordable Care Act — Glide exemplifies what policy experts say must be the new model of U.S. healthcare if it is to stay affordable: integrated care, disease management, prevention and wellness, interdisciplinary teamwork and patient-centered care. "We really practice what everybody preaches," said Tine Hansen-Turton, MGA, JD, CEO of the National Nursing Centers Consortium in Philadelphia. Despite their successes, nurse-managed clinics struggle for funding. Many insurance companies don’t fully reimburse for primary care provided by NPs, Hansen-Turton said, and many of the centers’ patients are uninsured, forcing the clinics to compete for a shrinking pool of government and private grants.
The constant scramble for funding could be eased considerably after full implementation of the Affordable Care Act in 2014, Hansen-Turton said. The ACA would increase healthcare coverage to the poor and uninsured through Medicaid expansion, insurance subsidies and state-run health insurance exchanges, creating more reimbursement possibilities for providers who care for uninsured people — the bulk of community clinics’ patient populations. The U.S. Supreme Court is considering whether to overturn some or part of the ACA, including provisions for insurance exchanges and Medicaid expansion. A ruling is expected by late June.
Reimbursement by third-party payer, whether public or private, "is the best lifeline for sustainability of these clinics," said Julie Sochalski, RN, PhD, FAAN, director of the Division of Nursing in the Bureau of Health Professions at the U.S. Health Resources and Services Administration, which allocates funds for nurse-managed health centers.
Cost-effective care
Nurse-run clinics have cared for the poor since social reformer Lillian Wald established the Henry Street Settlement in 1893. These clinics historically have focused on environmental and social barriers to good health. Recent data show nurse-managed clinics serving low-income and uninsured people boast a strong record of achievements and outcomes. Some studies have found lower hospitalization rates among patients in nurse-managed centers. A systematic literature review published in the British Medical Journal in 2006 found no difference in the quality of care between physicians and NPs, and found NPs had greater patient satisfaction ratings and spent more time with patients.
In 2010, the ACA authorized up to $50 million to build and run nurse-managed healthcare centers, and Congress allocated $15 million in grants to 10 established centers to expand care. After the initial release of funds, a tight budget and difficult economy kept Congress and President Barack Obama from requesting or allocating the remaining $35 million.
Patricia Dennehy, RN, DNP, FNPc, director of the nurse-managed health center at Glide and clinical professor at University of California-San Francisco School of Nursing, believes as nurse-run centers prove themselves, more funding will follow. "HRSA and the federal government are looking at these models very carefully," she said, "and I would expect to see more money to expand this model in the future."
HRSA understands the importance of the centers, Sochalski said. "We think they are a key in expanding access to healthcare." But her hands are tied when it comes to doling out more of the ACA funding. "It will be up to the Congress to decide if they are going to appropriate that money," she said.
The ACA authorization is not nurse-managed health centers’ only funding source, Sochalski said. Other grants are available through Title VIII of the Public Health Service Act, which encourages primary care providers to work with underserved populations. Some clinics also may be eligible to become Federally Qualified Healthcare Centers and receive funding through that program, she said.
Federal funding is important, Hansen-Turton said, but even more so is language in the ACA recognizing nurse-managed centers as a viable model of cost-effective, high-quality primary care for the underserved. The centers, as defined in the ACA, must be directed by an advanced practice RN and associated with a school of nursing, federally qualified health center or independent nonprofit health or social services agency. Most are associated with schools of nursing that pay the salaries of the director and sometimes other APRN care providers. In exchange, the centers serve as much-needed community health clinical sites for graduate and undergraduate nursing students.
Nurse-run clinics have cared for the poor since social reformer Lillian Wald established the Henry Street Settlement in 1893. These clinics historically have focused on environmental and social barriers to good health. Recent data show nurse-managed clinics serving low-income and uninsured people boast a strong record of achievements and outcomes. Some studies have found lower hospitalization rates among patients in nurse-managed centers. A systematic literature review published in the British Medical Journal in 2006 found no difference in the quality of care between physicians and NPs, and found NPs had greater patient satisfaction ratings and spent more time with patients.
In 2010, the ACA authorized up to $50 million to build and run nurse-managed healthcare centers, and Congress allocated $15 million in grants to 10 established centers to expand care. After the initial release of funds, a tight budget and difficult economy kept Congress and President Barack Obama from requesting or allocating the remaining $35 million.
Patricia Dennehy, RN, DNP, FNPc, director of the nurse-managed health center at Glide and clinical professor at University of California-San Francisco School of Nursing, believes as nurse-run centers prove themselves, more funding will follow. "HRSA and the federal government are looking at these models very carefully," she said, "and I would expect to see more money to expand this model in the future."
HRSA understands the importance of the centers, Sochalski said. "We think they are a key in expanding access to healthcare." But her hands are tied when it comes to doling out more of the ACA funding. "It will be up to the Congress to decide if they are going to appropriate that money," she said.
The ACA authorization is not nurse-managed health centers’ only funding source, Sochalski said. Other grants are available through Title VIII of the Public Health Service Act, which encourages primary care providers to work with underserved populations. Some clinics also may be eligible to become Federally Qualified Healthcare Centers and receive funding through that program, she said.
Federal funding is important, Hansen-Turton said, but even more so is language in the ACA recognizing nurse-managed centers as a viable model of cost-effective, high-quality primary care for the underserved. The centers, as defined in the ACA, must be directed by an advanced practice RN and associated with a school of nursing, federally qualified health center or independent nonprofit health or social services agency. Most are associated with schools of nursing that pay the salaries of the director and sometimes other APRN care providers. In exchange, the centers serve as much-needed community health clinical sites for graduate and undergraduate nursing students.
A personal approach
Although many of their operating principles are the same, clinics cater to the needs of their patient populations. Glide sees an urban, adult population, including many homeless people and those with mental illness and addiction problems. Its clients include patients with HIV/AIDS, diabetes and, more often, age-related illnesses such as cancer and cardiac conditions that have gone undiagnosed or untreated for years. "We see people whose health has been adversely affected by access issues," Dennehy said.
Sheridan (Colo.) Health Services started as a school-based clinic in 1995 and serves mostly Hispanic families in a low-income suburb of Denver. An ACA grant allowed it to open an adult primary care center across the street from the Colorado Mental Health Institute. "There are zero resources here," said Erica L. Schwartz, RN, DNP, MSN, CNM, assistant professor at the University of Colorado-Denver College of Nursing and executive director of Sheridan Health Services, "and there is such a high need for healthcare."
East Tennessee State University in Johnson City received ACA funds for three of its nurse-managed clinics. Two are in rural areas of the poorest counties in the state, and another is in downtown Johnson City, where 15% of the 63,000 residents live below the poverty line, said Patti Vanhook, RN, PhD, FNP-BC, clinic director and assistant professor and associate dean for practice and community partnerships at ETSU College of Nursing. One of the rural clinics is in a school, and the other shares space with a two-bed critical access hospital and provides the county’s only prenatal services. Nearly 60% of the three clinics’ patients are uninsured. The ACA grant has allowed Vanhook to expand clinic hours and add a second NP to provide care in one of the rural clinics.
Despite the poverty and complex conditions of their patients, outcomes for hypertension, diabetes management and low birthweight rates are better than state and national rates, Vanhook said. Last year the three clinics — which had 30,000 patient visits — had an average cost of $106 per patient. That is well below the annual cost of care for community health centers — $515 per patient — and many times less than the average per-capita spending on personal healthcare. "I think that’s the connection with the patient. We’re really trying to work diligently with the patients and the health team to understand what it means to manage their disease, and that what they do has an impact on their health," Vanhook said.
The clinic directors said they would prefer to receive care themselves in nurse-managed health centers if their insurance covered it. Sheridan Health Services is in the process of contracting with two HMOs so the clinic can see more insured patients. "Absolutely I would get my care here," Schwartz said, citing the integration and wellness component she feels her healthcare arrangement lacks. "It would be great to get all of my healthcare in just one place." •
Although many of their operating principles are the same, clinics cater to the needs of their patient populations. Glide sees an urban, adult population, including many homeless people and those with mental illness and addiction problems. Its clients include patients with HIV/AIDS, diabetes and, more often, age-related illnesses such as cancer and cardiac conditions that have gone undiagnosed or untreated for years. "We see people whose health has been adversely affected by access issues," Dennehy said.
Sheridan (Colo.) Health Services started as a school-based clinic in 1995 and serves mostly Hispanic families in a low-income suburb of Denver. An ACA grant allowed it to open an adult primary care center across the street from the Colorado Mental Health Institute. "There are zero resources here," said Erica L. Schwartz, RN, DNP, MSN, CNM, assistant professor at the University of Colorado-Denver College of Nursing and executive director of Sheridan Health Services, "and there is such a high need for healthcare."
East Tennessee State University in Johnson City received ACA funds for three of its nurse-managed clinics. Two are in rural areas of the poorest counties in the state, and another is in downtown Johnson City, where 15% of the 63,000 residents live below the poverty line, said Patti Vanhook, RN, PhD, FNP-BC, clinic director and assistant professor and associate dean for practice and community partnerships at ETSU College of Nursing. One of the rural clinics is in a school, and the other shares space with a two-bed critical access hospital and provides the county’s only prenatal services. Nearly 60% of the three clinics’ patients are uninsured. The ACA grant has allowed Vanhook to expand clinic hours and add a second NP to provide care in one of the rural clinics.
Despite the poverty and complex conditions of their patients, outcomes for hypertension, diabetes management and low birthweight rates are better than state and national rates, Vanhook said. Last year the three clinics — which had 30,000 patient visits — had an average cost of $106 per patient. That is well below the annual cost of care for community health centers — $515 per patient — and many times less than the average per-capita spending on personal healthcare. "I think that’s the connection with the patient. We’re really trying to work diligently with the patients and the health team to understand what it means to manage their disease, and that what they do has an impact on their health," Vanhook said.
The clinic directors said they would prefer to receive care themselves in nurse-managed health centers if their insurance covered it. Sheridan Health Services is in the process of contracting with two HMOs so the clinic can see more insured patients. "Absolutely I would get my care here," Schwartz said, citing the integration and wellness component she feels her healthcare arrangement lacks. "It would be great to get all of my healthcare in just one place." •
Cathryn Domrose is a staff writer. Write to editor@nurse.com or post a comment below.
