Nurse-Managed Clinics and Strategies
for Enhancing Workforce Development
in the States
The National Academy for State Health Policy
State Health Policy Conference - October 2011
Nancy L. Rothman, EdD, RN
Consultant/PHMC Nursing Network
Independence Foundation Professor of Urban
Community Nursing
Dept. of Nursing, CHP and SW, Temple University
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Today’s Presentation
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A broad overview of Nurse-Managed Health Clinics
(NMHC)
The current role of NMHCs in workforce development
Why expanding the role of NMHCs is critical to the
success of state workforce development and health
care reform efforts.
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Massachusetts Case Study
Pennsylvania Case Study
Discuss some of the challenges facing NMHCs and
strategies for supporting the nurse-managed model.
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What is a Nurse-managed Health
Clinic (NMHC)?
•
A nurse managed health clinic is a nurse practice arrangement,
managed by advanced practice nurses, that provides primary care or
wellness services to underserved or vulnerable populations and that is
associated with a school, college, university or department of nursing,
federally qualified health center, or independent nonprofit health or
social services agency. Source: Affordable Care Act (ACA)
Characteristics:
•
NMHCs are accessible service sites that deliver community-based
primary and/or wellness care regardless of a patient’s ability to pay.
•
The majority of care is provided by nurses—a team of advanced
practice nurses (Nurse Practitioners, Clinical Nurse Specialists, Nurse
Midwives), RNs and other health professionals (e.g. Social Workers,
Nutritionists) in collaboration with MDs in jurisdictions where required.
•
Dominant theme: Nurses control their own practice and provide the
care.
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Nurse-Managed Health Centers
Generally

Currently over 250 nursemanaged health centers
operate throughout the
United States, serving
diverse communities in
urban, rural, and suburban
locations.
Source: NNCC Member Survey, 2008
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Services Provided
•
The majority of patients are on
Medicaid or uninsured.
They receive:
•
Primary Care
•
Mental/Behavioral Health
•
Family Planning
•
Prenatal Services
•
Disease Prevention
•
Health Promotion
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MOST COMMON NMHC
DIAGNOSES/REASONS FOR VISITS
•
•
•
•
•
•
•
•
•
•
Hypertension
Depression
Diabetes
Child Health Exam
Hyperlipidemia
Adult Health
Maintenance Exam
Obesity
Upper Respiratory
Infection
Asthma
Normal pregnancy
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NMHCs and Workforce
Development
•
According to national data from the Institute for Nursing
Centers, over 90 schools of nursing operate NMHCs. All
together there are approximately 184 academically-run
NMHCs in the U.S.A.
Benefits:
1.
NMHCs provide clinical placements for undergraduate and
graduate nursing students necessary to increase enrollment in
nursing education programs – helping to eliminate shortages in
supply of nurses.
2.
NMHCs provide primary health care experience with underserved
populations. This exposure enhances the chance that the
students will select to practice in underserved areas.
3.
NMHCs give students the unique opportunity to integrate
classroom learning with community-based care.
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What Students Say About NMHCs
•
The community-based experiences were not found in
other clinical rotations.
•
Patient populations were diverse.
•
Health disparities were visible.
•
NMHCs were ideal settings to teach business and
financial concepts.
•
Nursing practice is consistent with conceptual models of
nursing presented in the classroom.
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Why Including NMHCs in
Workforce Development
Effort is Important to State
Health Care Reform…
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State Case Studies: MA and PA
• Massachusetts invested in insurance access
before ensuring it had the infrastructure to
handle increased demand for services.
• In Pennsylvania, Governor Rendell invested in
health care infrastructure first, setting the
stage for insurance reforms in the future
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MA Reform Overlooked
Workforce Development
•
Since 2006, Massachusetts has gone from having as
many as 650,000 uninsured residents to having 167,300
today (the lowest rate of uninsured residents in the
nation).
•
But, the State was not prepared for the influx in newly
insured residents.
•
Primary physicians were quickly overwhelmed.
•
In order to meet increased demand, in 2008, the state
enacted a law increasing utilization of NMHCs, nurse
practitioners and other non-physician providers.
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PA Reform: Legislative Change
PA Reform called for approximately 49 statutory/regulatory
changes to allow NPs to practice to the full extent of their scope
of practice. NPs in PA can now:
5. Make respiratory and
1. Order home health and hospice
occupational therapy referrals
care
6. Perform disability
2. Order durable medical
assessments for the program
equipment
providing Temporary
3. Issue oral orders to the extent
Assistance to Needy Families
permitted by the state’s health
(TANF)
care facilities
7. Issue homebound schooling
4. Make physical therapy and
certifications
dietitian referrals
8. Perform and sign the initial
assessment of methadone
treatment evaluations
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PA Reform: Inclusion of NMHCs in
PCMH Projects
In 2008, the Governor’s Office of Health Care Reform, along
with physicians, nurses, and insurers, successfully began the
implementation of Wagner’s Chronic Care Model in selected
primary care practices in Southeastern PA. Eight of the initial 32
practices were nurse-led.
In 2010, the initiative was expanded through out the state and
now includes 151 participating practices.
Outcomes are extremely positive - 2009 data shows that
participating diabetics are 33% more likely to have control of
their blood sugars, 40% more likely to have control of cholesterol
levels and 25% more likely to have normal blood pressures
when compared to non-participating diabetics.
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Strategies for Fully Utilizing NMHCs
IOM’s Future Nursing Report Message:
•
Nurses should practice to the full extent of their education and
training. (Requires scope of practice reform)
•
Nurses should achieve higher levels of education and training
through an improved education system that promotes
seamless academic progression. (Requires promulgating
NMHCs and providing access to students for clinical sites)
•
Nurses should be full partners, with physicians and other
health professionals, in redesigning healthcare in the United
States. (Requires including NMHCs in ACOs and state
insurance exchanges)
•
Effective workforce planning and policy-making with better
data collection and information infrastructure. (Requires
promoting NMHC participation in Patient Centered Medical
Home projects, as NCQA did in October, 2010)
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Remaining Challenges
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•
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Securing Participation in Medical Home Projects - Many
Medical Home documents and demonstration projects still
contain physician centered language which prohibit NMHC
participation i.e. AAFP’s Joint Principles for the Patient
Centered Medical Home.
Securing Participation in Accordable Care Organizations
–The draft ACO regulations contain physician centered
language which will make NMHC participation difficult.
Securing Participation in Managed Care- 48% of all major
managed care organizations do NOT credential nurse
practitioners as primary care providers.
Securing Federal Funding- The ACA created a new grant
program for NMHCs which received $15 million from the
Public Health Prevention Fund in 2010. But deficit reduction
efforts are putting the future of the program in jeopardy.
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For More Information
Nancy L. Rothman
Email: rothman@temple.edu
Phone: 215-707-5436
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