Advance Practice Nurse Led Clinics – Coming to Your Medical Neighborhood Soon?
In celebration of National Nurse Practitioner week, Drs. Norah Johnson and Kristin Haglund provide a glimpse into a developing trend between academic nursing institutions and nurse led clinics. In their overview of Marquette Neighborhood Health Center (MNHC) in Wisconsin, they illustrate the symbiosis that can be found between a nursing school seeking resident NP training and the desire to improve the communities that they serve. Through its affiliation with the Marquette University College of Nursing, MNHC delivers primary care, health promotion, physical exams and diagnosis and treatment of common illnesses in a federally designated primary care health professional shortage area, located in downtown Milwaukee. Since 2007, this NP led clinic has treated local residents, Marquette University students and employees, clients of the Salvation Army, and clients of the Milwaukee Center for Independence.
Predominantly serving a Medicaid population, this nurse-managed health center now finds itself facing many issues regarding sustainability. Not meeting the current requirements of a federally qualified health center (FQHC), no matching federal funding opportunities exist. Rather, nurse led clinics often rely on the support of university funding via an academic partner, leaving it in competition for dwindling dollars. And while Medicaid does reimburse for Nurse Practitioner services, it is generally at a rate one-third less (66%) of a standard primary care visit. Medicaid reimbursement rates are projected to improve for 2013/14; however, only those delivered by a physician specializing in family medicine, internal medicine, pediatric medicine OR a nurse practitioner working and billing under the supervision of a qualifying physician. While this is a positive step for increasing the Medicaid provider panel, it will not generate additional revenue for MNHC since the NPs bill under their own Medicaid provider numbers.
Having recently written about the dwindling number of Medicaid providers in the state with the highest uninsured rate, I would be curious to know how the Centers for Medicare and Medicaid Services (CMS) would view the inclusion of nurse led clinics in the medical home? By developing affiliations with accountable care organizations, nurse practitioners gain access to referral sources for higher acuity services and capital for infrastructure and improvements. Additionally, drawing this vulnerable population into a continuum of care paves the way for reducing inappropriate utilization of more expensive outlets for primary care – namely the emergency department. Thus, savvy hospitals, healthcare systems, physician groups and payers participating in or modeling new payment arrangements not only reap the benefit of prevention, wellness and subsequent reduced readmissions, they also have the opportunity to engender loyalty amongst an influential group of expanding primary care providers and expand their recruitment pool. Most importantly, with a new entry point into these redesigned delivery mechanisms, increased numbers of un/underinsured persons have the potential to receive care; albeit not without the changes to the Medicaid reimbursement rate for the NP led clinic clinician in a medical home.
In addition to funding challenges, MNHC struggles with a high no-show rate. In working with a medical home, MNHC would have the ability to employ an electronic medical record and participate in direct messaging or a health information exchange, services not typically found in a siloed NP led clinic. Layer in population health management tool and these front-line providers begin to have the ability to improve their breadth and depth of services rendered. Marry this with appropriate messaging for appointment reminders, medication maintenance and others identified in the webinar below and the potential exists to transform the manner in which this critical population accesses healthcare – a fundamental necessity for bending the cost curve and transforming the way healthcare is delivered today.
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