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Top-notch care around the corner: APN-run clinics are gems to neighborhood residents

Monday May 21, 2012
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Erica L. Schwartz, DNP, MSN, CNM, wishes she could be a patient at her own clinic, Sheridan (Colo.) Health Services, a nurse-managed health center serving a low-income suburb of Denver. She believes the primary care there, provided by advanced practice nurses, is every bit as good as what she gets through her insurance, which does not cover care at Sheridan. What the nurse-run clinic offers that more traditional primary care does not, she said, is a strong wellness component.

With traditional care, “I go in if I have a problem, they address the problem and that’s it,” said Schwartz, executive director of Sheridan Health Services and assistant professor at the University of Colorado Denver College of Nursing. “I’m just processed through.”

Since she doesn’t have any chronic health problems, she said, the system works OK for her. But she says her clinic — with its health education programs, prevention services and integrated providers — offers ideal care for any population. “I think it would be nice to have nurse-managed health centers be the norm as gatekeepers of primary care,” Schwartz said.

Since Lillian Wald established the Henry Street Settlement in 1893 to provide health and education to the poor of New York, nurse-managed clinics have emphasized the importance of a holistic approach to overcome social and environmental barriers to health, instead of merely treating disease. Some 250 clinics managed by APNs currently operate in the U.S., according to the National Nursing Centers Consortium.

In addition to treating minor ailments and offering behavioral health services, they emphasize prevention, wellness and health education for their patients, many of whom are homeless or low-income and at risk for chronic health problems.

Sense of community

Preventing illness is a “big thing” to nurse practitioners, said Patricia Dennehy, RN, DNP, FNPC, FAAN, director of Glide Health Services, a nurse-managed clinic in San Francisco’s low-income Tenderloin neighborhood. “We tell people to come here when they are sick, but also to come when we can prevent illness. So when they come in for physical exams, we order labs and screen for different illnesses, and when we find an illness, we treat it accordingly.”

The clinic serves a large homeless population, as well as poor, working adults. A partnership among the University of California, San Francisco School of Nursing; Saint Francis Medical Center; and the Glide Foundation, it operates in the same building as Glide Memorial Methodist Church, which runs a free meals program. Glide Health Service’s eight NPs provide primary care to some 3,000 people and work with a web of community providers to ensure patients have access to addiction treatment and mental health programs. The clinic has HIV services and a team of behavioral health providers on the same floor as its primary care offices. Its new wellness center occupies most of the floor below.

The wellness center offers patient education, complementary healing and movement classes such as tai chi. “We have a lot of patients with chronic pain, so they do other modalities to treat their chronic pain, such as acupuncture, yoga or meditation,” said Karla Ballesteros, RN, MSN, an FNP at the clinic. The classes create a sense of community while helping people stay healthy, Dennehy said. “We just want to give people a chance to be in community and be in health.”

The center also offers classes in healthy eating and cooking, stress reduction, smoking cessation and domestic violence.

Glide’s providers tailor programs to the population they serve. Diabetes education classes, for instance, include regular foot-care sessions: Patients’ feet are washed, wounds are treated and they each receive a clean pair of socks — a luxury for those who live on the streets.

NPs also have creative ways of keeping in touch with their patients, who often do not have phones or permanent addresses. Ballesteros has worked out a system with a patient who was diagnosed with liver cancer. Twice a week he calls her cell phone for an update on his care plan, including lab results and appointments with a specialist. If she’s not available, he knows to call back. “We try to keep people from falling through the cracks,” Dennehy said.

For a while, Glide patients had high no-show rates for colonoscopies. NPs developed a system of steps to determine whether patients were likely to complete the procedure. After an initial appointment, patients were asked to return to watch an educational film. Then, with money from a grant, the clinic arranged for those who agreed to have a colonoscopy to stay in a hotel to give them access to a toilet during the prep. “We tripled the completion rate,” Dennehy said, with 80% showing up for the test.

Stretching dollars

Sheridan Health Services started as a school-based clinic in 1995, serving mostly Hispanic families; a grant through the Affordable Care Act allowed it to open an adult primary care center across the street from the Colorado Mental Health Institute. Its prevention and wellness services include health history and behavioral health screenings, chronic disease management, immunizations and guidance on topics such as nutrition, substance abuse, family planning and sexuality. An RN case manager works with patients on health education and setting good health goals, and public health nurses make home visits to assess barriers to meeting those goals.

Besides providing basic primary care, NPs at the clinic provide prenatal care.

East Tennessee State University received ACA funds for three of its nurse-managed clinics — two in rural areas of the poorest counties in the state and another in downtown Johnson City, which has about 63,000 residents, 15% of whom live below the poverty line, said Patti Vanhook, RN, PhD, FNP-BC, clinic director and associate dean of practice and community partnerships at ETSU College of Nursing. An important focus of the clinics’ work is involving the patients in their own care, Vanhook said. “We’re 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.”

Despite the poverty and complex conditions of their patients, outcomes for hypertension, diabetes management and low-weight birthrates are better than both the 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, she said. That is well below the National Association of Community Health Centers’ 2006 estimate of $515 average cost per patient seen in U.S. community health centers.

The Tennessee clinics are not alone in their success rates. Recent data shows nurse-managed clinics serving low-income and uninsured people boast a strong record of achievements and outcomes. Some studies have found lower rates of hospitalization 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 rates and spent more time with their patients.

Recognizing the importance of nurse-managed clinics, the Affordable Care Act that became law in 2010 authorized up to $50 million for nurse-managed healthcare centers. That year, Congress allocated $15 million in grants to 10 well-established centers across the country to expand their brand of care, including Glide, Sheridan and East Tennessee State. But after that initial release of funds, a tight budget and difficult economy have kept Congress and President Obama from requesting or allocating the rest of the $50 million for nurse-managed clinics.

“We fell into that group of exciting new things Congress wanted to fund,” said Tine Hansen-Turton, MGA, JD, CEO of the NNCC, but was unable to because of the recession. Dennehy believes that as nurse-run centers prove themselves, more funding will follow. “HRS 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.”

The U.S. Health Resources and Services Administration also funds 24 nurse-managed clinics through Title VIII of the Public Health Services Act. Data collected from the clinics will add to a growing body of evidence on the success of the wellness model, Hansen-Turton said, including cost savings on outcomes as good as those of any other provider.

In the meantime, some private payers may be starting to appreciate the value of the nurse-managed centers’ emphasis on prevention and wellness. Schwartz is working to get a contract with two private insurers, including one who covers her own care, and once that happens, she plans to become a patient at her own clinic. Her mother, who is uninsured, already receives all her care at Sheridan. “She gets calls from the nurse practitioner about her blood pressure,” Schwartz said. “She thinks it’s amazing.” •

Student training

As the need for community health providers increases, so does the need for clinical sites to train them. Many small community clinics do not have the ability to mentor and instruct students. But most nurse-managed health centers are associated with schools of nursing that pay the salaries of the director and sometimes other advanced practice nurses providing care for vulnerable populations. In exchange, the centers serve as much-needed clinical sites for graduate and undergraduate nursing students who want to work in community health and wellness-based settings.

“They are a very important part of their communities,” said Julie Sochalski, RN, PhD, FAAN, director of the division of nursing at the U.S. Health Resources and Services Administration, which allocates funds for nurse-managed health centers. “They also are great places for workforce training.”

Many nurse-managed clinics work with other schools of health professions to help train students in fields from dentistry to physical therapy. The arrangement provides extra needed help and expertise for the clinics, and a real-life lesson in integrated care for students who learn to work as a team. Last year, East Tennessee State University in Johnson City had 113 students working at its nurse-managed clinics, including nurse practitioner, undergrad RN, pharmacy and medical students. “We’re trying to create an integrated environment for students and patients,” said Patti Vanhook, RN, PhD, FNP-BC, clinic director and associate dean of practice and community partnerships at ETSU College of Nursing.

Glide Health Services in San Francisco is part of a NP residency program created by the Affordable Care Act that gives new APNs a nurturing place to learn and practice community health. Residents spend 24 hours a week with patients. The rest of the time they review their work with a preceptor, work on special projects and attend rounds with medical residents at San Francisco General Hospital. They also meet regularly with a psychologist who talks with them about their new role and the stresses that go with it.

“Without this mentoring, we would find it hard to hire somebody just out of school because people really need a little more time,” said Patricia Dennehy, RN, DNP, FNPC, FAAN, Glide director and clinical professor at the University of California, San Francisco School of Nursing. “We believe this is a model that is going to move more nurse practitioners into the safety net.”

Elisabeth Goldstein, RN, NP, a resident at Glide, says she feels fortunate to be in the program, especially after talking to other new NPs who report feeling stressed and overwhelmed at jobs where they might see 12 patients a day. She sees three or four, with her preceptor working with her after every visit. The support she receives reflects the clinic’s emphasis on holistic health and wellness for its staff as well as its patients. “The model here is of people who are very dedicated to their work,” she said. “But they seem to have a good sense of taking care of themselves as well.”



Cathryn Domrose is a staff writer.