Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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Grant
I.
Abstract
With a primary care shortage and health care reform in the future, how can providers be
prepared for the inevitable? What will occur once the uninsured become insured? A solution to
this is to train the nurse practitioners in community health care settings to help with the increase
in demand of providers. For decades nurse practitioners have shown to be cost-effective in
taking care of patients. The purpose of the proposed quantitative research is to adapt a NP
residency program in a community clinic. New nurse practitioner graduates can train in a sixmonth residency program to gain the skills and competency needed to provide quality care as
part of a collaborative physician/nurse practitioner model. The major objectives of the study are
to measure NP patient outcomes after implementation MD/NP working model. Measurable
objectives will be measured through evaluation tools. The evaluation tools will measure NP
competency and patient outcomes compared to pre MD/NP model of care. This new model
supports the growth of collaboration between physicians and nurse practitioners in
communication and by enhancing each other’s profession. This type of model has demonstrated
to be cost-effective and money preserved can be applied to services provided by community
health care centers.
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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Background
Initially the nurse practitioner (NP) role was based on knowledge and skills of the public
health nurse to promote cost efficiency and primary contact in underserved areas (Clarion
University, 2010). A collaborate practice was intended to combine the knowledge and skills of
the clinicians to increase access to patient services (Clarion University, 2010). NP’s and
physicians can work together in a collaborative practice to help educate and counsel patients in
disease prevention, promote wellness, and increase adherence to treatment (Clarion University,
2010). As NP’s continue to increase nationwide at an average of 5,500 annually (American
Academy of Nurse Practitioners (AANP), 2009), this can aide with the physician shortage as it
continues (Bishop, 2009).
There are many factors that have contributed to the physician shortage, such as a
reduction in work hours, mid-level providers providing care, and the growth of the United States
population (Cooper, 2002). The current trend is moving primary care away from physicians to
NP’s or physician assistants (PA’s) (Cooper, 2002). More insurance and health plans are
covering care provided by mid-level providers (Cooper, 2002).
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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NP’s have been practicing in the United States since 1965, they helped promote wellness
and prevent diseases in the pediatric population (Bishop, 2009). Currently there is a physician
shortage in primary and specialty care (Cooper, 2002). The recent literature measuring NP care,
patient outcomes, and cost effectiveness has shown that NP’s can provide quality care
comparable to a physician. NP’s can help alleviate the physician shortage and work together
with physicians. If NP’s do not accrue more costs and provide quality care than why not work
together with NP’s to help alleviate the physician shortage and help aide in healthcare reform?
Executive Summary
The Association of American Medical Colleges has estimated that Americans are living
longer (AANP, 2007). Demands on visits will increase quicker (Bishop, 2009). Nurse
practitioners (NP) will be part of the solution to improving patient care and increasing access to
patients (Bishop, 2009).
In the presence of health care reform, there will be an increase in demand of services. In
2006 health care in Massachusetts was expanded to most residents of the state (Bodenheimer &
Pham, 2010). However, the primary care workforce was unable to meet the demands of new
patients (Bodenheimer & Pham, 2010). The average wait time to see a primary care provider in
Massachusetts in 2008 was thirty-one days (Bodenheimer & Pham, 2010). It was also
discovered that 21 percent of Medicare patients and 31 percent of private insured patients were
unable to obtain an appointment for routine care in 2008(Bodenheimer & Pham, 2010). In
Massachusetts it was seen how expanding care without expanding access lead to patient and
provider disappointment (Bodenheimer & Pham, 2010). With the United States leading in the
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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direction of health care reform like in Massachusetts without increasing the primary care
workforce, than the rest of the United States will be in a similar situation or be worse.
Description of the Present Situation
Even though there is a shortage of primary care physicians, primary care doctors are
being recruited in specialty areas because there is a shortage there as well see figure 2 (Cooper,
2002). Income for primary care physicians is far less then specialty care areas see figure1
(Josiah Macy, Jr., Foundation (JMJF, 2010). Specialty area physicians earn twice as much as a
primary care physician (JMJF, 2010). In addition, internal medical residents are choosing career
as hospitalists, specialists, instead of general medicine (JMJF, 2010).
Goal
To provide competent, quality care, and increase access to members of the community.
Objectives
1. To train two nurse practitioners to go through a residency program to increase access to
healthcare throughout the lifespan from pediatrics to geriatrics.
2. Monitor evaluation and progress through patient outcomes.
3. Adapt a MD/NP model to care for patients across the lifespan.
Option # 1
Do nothing and not hire or train midlevel providers. If we do not address these issues we
will have decreased job satisfaction among primary care providers and run the risk of losing
primary care providers.
Option #2
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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Hire four additional nurse practitioners to train in primary care to increase
provider satisfaction and not lose providers.
Cost/Benefit Analysis
Many analyses have been done on NP practice. According to the AANP, NP’s can
manage 80% of adult primary care and 90% of pediatric care (AANP, 2007). Median
compensation for a primary care physician is $130,000 to $208,700 depending on the practice
(Lowes, 2005). The median salary for an NP is $71,000 with a mean of $73,630 (AANP, 2004).
A recent study found that NP’s cost of labor per visit was lower and that they were used to a
greater extent (Roblin, Howard, Becker, Adams, & Roberts, 2004).
Chenowith, Martin, Pankowski, & Raymond (2005) found that an on-site NP practice
resulted in a savings of $.8 to 1.5 million with a cost ratio of 15 to 1. The physician-NP team is
associated with decreased costs and a decrease in mortality (AANP, 2007).
Market Analysis
If primary care is the foundation of the future healthcare system in this country, and if
access to primary care for all is to be assured while containing or reducing costs of care, NPs will
play a crucial role in achieving these aims (JMJF, 2010). In many countries, primary care for
women and children is provided by nurse midwives, nurses, and community health workers, with
outcomes superior to the United States (JMJF, 2010). “Collaboration among providers is
essential, and all providers must be able to practice to their fullest capacity and educational
preparation without erroneous and unnecessary regulations that are not evidence based” (JMJF,
2010).
Explanation of the program and its implementation
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
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Each nurse practitioner resident will rotate through the agency services. The residents
will work with a primary care team and direct patient care as assigned by the team. Every
resident will be assigned a dedicated preceptor. The residents will rotate through the different
services in adult primary care, woman’s health, pediatrics, and family care. On the 5th day the
resident will go to a weekly didactic session directed by the program director that will discuss
common diagnosis and treatments in the region or agency setting.
Timeline and schedule For Implementation
See Appendix A
Description of program leader and resources needed
The program director will be in charge of marketing and the application process, along
with working collaboratively with the agency. The director will also lead the didactic sessions
and address any problems that arise during the residency program. The program director will be
a family nurse practitioner. A community health care center would be most appropriate for the
program since main services already exist in this setting.
Evaluation of program
To determine if educational objectives are met, the program director will evaluate the
objectives. The preceptor will evaluate each resident and/or program director by the NP
competencies set by the National Organization of Nurse Practitioner Faculties.
Financial
See Appendix B
Profit/net Income
See Appendix B
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
References
American Academy of Nurse Practitioners. (2007). Nurse Practitioner cost-effectiveness.
Retrieved 3/11/2010, from
http://www.hospitalmedicine.org/AM/Template.cfm?Section=Reference_Material
&Template=/CM/ContentDisplay.cfm&ContentID=16740
American Academy of Nurse Practitioners (2009). Nurse Practitioner Facts.
Retrieved 3/11/2009, from http://www.aanp.org/NR/rdonlyres/54B71B02-D4DB4A53-9FA6-23DDA0EDD6FC/0/NPFacts6.pdf
Bishop, C. S. (2009). The Critical Role of the Oncology Nurse Practitioners in Cancer
7
Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
Care: Future Implications. Leadership and Professional Development, 36(3), 267269.
Chenowith, D., Martin. N., Panlowski, J., & Raymond, L. W. (2005). A benefit-cost
analysis of a worksite nurse practitioner program: First impressions. Journal of
Occupational and Environmental Medicine, 47 (11), 1110-1116.
Clarion University. (2010). Collaborative practice. Retrieved May 6, 2010 from
http://www.sru.edu/pages/3620.asp
Cooper, R. A. (2002). There’s a shortage of specialists. Is anyone listening? Academic
Medicine, 77(8), 761-766.
Josiah Macy, Jr. Foundation. (2010). Who will provide primary care and how will they
be trained? Proceedings of the conference. Durham, N.C.
Landro, L. (2008). The Informed patient: Making Room for ‘Dr. Nurse’. Wall Street
Journal, D-1.
Lowes, R. (2005). Exclusive survey: The earning freeze-now it’s everbody’s problem.
Medical Economics, September 16, 2005.
Roblin, D.W., Howard, D.H., Becker, E.R., Adams., & Roberts, M.H. (2004). Use of
midlevel practitioners to achieve labor cost savings in the primary care practice of
an MCO. Health Services Research, 39 (3), 607-626.
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Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
Figure 1. Primary care income far less than most other specialties
Figure 2. Carreer plans following IM residency
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Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
Appendix A
NP Residency Timeline June 2011-May 2011
January 2011 – Marketing and recruitment
February 2011- Marketing and recruitment
March 2011- Develop Evaluation tools/measures
April 2011 – Finalize Applicant Selection
May 2011 – Orientation/Physicals/Paper work
June 2011 – Preceptor training for 4 weeks in specialty area
July 2011- End of training/Preceptees with their own schedule/Residency
August 2011- Available to preceptors for consultation/ own schedule/Residency
September 2011- Mid Program Evaluation Residency
October 2011 - Residency
November 2011- Residency
December 2011 – End Program Evaluation/Residency
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Running head: A NURSE PRACTITIONER RESIDENCY PROGRAM
Appendix B
Budget for NP Residency Program 2011-2012
Salaries and Wages:
Personnel:
Direct Costs:
Preceptors Stipend or Gift to agency
$100/month*6months*2
NP Residents (2 residents)
$50/hr*8hr/day*3days/wk*2 (26 weeks)
Part-time benefits 18%
3.2 FTE’s
Indirect Costs:
Program Director
$1,200
$62,400
$11,232
$3,500
Marketing
$300
Supplies:
Laptop
$2500
Total Expenses:
$81,132
Revenue:
24 weeks of work after training
2 NP Residents in clinics
16 visits per day at $100/visit*20(2)(3)
Labs/tests/procedures 10%($10)
Revenue:
$192,000
$19,200
$211,200
Expenses:
ROI:
Shared Costs
($81,132)
1.60*100=160%
$73,632 (NP salaries)
$2500 (Laptop)
Proposal for grant
$1200 (stipend for clinic)
$300 (marketing)
$3,500 (Program Director)
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