Nurse Managed Health Centers

ABSTRACT
There has been an enormous focus on the impending increase in baby boomers approaching the year 2025 and the predicted shortage of primary care providers. This focus has only increased with the implications the Affordable Care Act has created through its provisions of increased insurance coverage for the uninsured. The numbers that are being predicted as shortfalls of health care providers may be exaggerated under many estimates or under-represented in others. The authors in, “Nurse Managed Health Centers and Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortages,” analyzed the impact of two emerging models of care—the patient-centered medical home and the nurse –managed health center. These are two models which use a provider mix that is richer in nurse practitioners and physician assistants than today’s predominant models of care delivery. The research found that these new models could have an impact on the projected shortages of primary care positions in certain circumstances.

INTRODUCTION SUMMARY
The article, “Nurse-Managed Health Centers and Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage,” examines the projected shortages of primary care physicians that are estimated to occur in 2025. This shortage as was discussed by Shi and Singh in the text, “Delivering Health Care in America pages 132-135 6th Edition. The authors, Auerbach, Chen, Friedberg, Reid, Lau, Buerharm, and Mehrota state on page 5, “projections indicate that if nothing changes we will face a large shortage of primary care doctors and potential surpluses of physician assistants and nurse practitioners by 2025.” (2013)This study analyzes the production model of anticipated physicians, nurse practitioners, and physician assistants for the future.

It compares the status quo of current output trends around medicine with two new models that revolve around the medical home staffed by an interdisciplinary team, and a nurse managed health center. Both models are shown through this study to impact the provision of health care in a positive way. Specifically, a shortage of primary care physicians given a number of possible forecasts. These solutions may be things to consider in looking toward the future trends associated with the outcomes of more insured individuals and the need for primary care services. Throughout this paper the main points of how this analysis was conducted, and the major conclusions arrived at will be reviewed. The implications for future healthcare options will also be discussed. It was an appealing article as it has real application for delivery of care in assisted living, home care and nursing homes for the aging long-term care population.

STUDY DESIGN
This study utilized a systematic review of previous information, published studies and data that was available. The authors methodically reviewed areas of estimated provider supply and demand, estimated production functions, and surplus shortage analysis each using a number variations and scenario planning that could change the outcomes obtained. They were able to use data, surveys and public literature reviews to access relevant studies and research on estimation and projections for Physicians, Nurse Practitioners, and Physician Assistants. PURPOSE OF REVIEW

The purpose as stated in the article on page 1 was to, “show how projections would change under different scenarios involving greater or lesser adoption of new models of care delivery and depending on how models are staffed.” (Auerbach, Chen, Friedberg, Reid, Lau, Beurhaus, and Mehrotra 2013) This review has meaning beyond the desire to show how projections would change and staffing shortages could be mitigated. Current trends show an increasing number in the aging population and how alternatives are going to be needed to provide appropriate care in an expanding and complex long-term care system. The financing moreover staffing of long-term will remain a major challenge. (Shi & Singh 2015)

This information is intriguing as the long term care industry looks for alternatives to ensure individuals can stay where they want, as long as they want, with coordinated high-quality care. This level of care will only occur through good communication, technology, workforce supply, financial provisions and resources, as well as overhauls of regulations and the entire framework of the long-term care system. This study noted that one of the critical issues is that the scope of practice laws, workforce supply and level of training as well as payment systems will have to change in order to be able to implement what the results of their analysis have shown. However, it implies that alternatives are available to mitigate the impending shortages and surpluses in health care delivery.

Major Conclusions
The authors came up with three main points that support their overall conclusions. These points included confirming what other current forecasts have found. There will be large shortages across the nation in primary care physicians but surpluses of physician extenders or nurse practitioners. (Auerbach, Chen, Friedberg, Reid, Lau, Buerhaus 2013) These results could be skewed based on timing, and new initiatives promoted by the Affordable Care Act.

The second point that this analysis showed is there are marked differences in the reporting of supply and demand outcomes under different assumptions about how care is delivered. Most models assume that the use of doctors in primary care will stay stagnant at the same level it has been for years into the future. The authors found the forecasted physician shortage noted of 20 percent, could be nearly eliminated with continued growth in the emerging medical home and nurse-managed health center models. (Auerbach, Chen, Friedberg, Reid, Lau, Buerhaus 2013)

Lastly, they found that their review and analysis of others work and data showed that medical homes and nurse-managed care centers could greatly impact some of the maldistribution projected the US will experience in the future. They found if the number of nurse-managed centers in primary care increased by a modest amount, the expected deficits could be lower related to the fact that the nurse-managed model relies heavily on nurse practitioners versus physicians or physician assistants.

These three points lead to the overall conclusions that there are models out there, if utilized in a creative way, that have the potential to change the projected shortage of primary care physicians and address the surplus of physician assistants and nurse practitioners. Their conclusion is easy to embrace based on the readings of Shi and Singh around mal-distribution and the differences between the two. The proportion of active PCP has been declining since 1949. (Shi and Singh 2015) With the ACA focus on prevention and health promotion a nurse practitioner may be easier to obtain, promote funding for, and achieve outcomes sooner than utilizing more physician assistants who are trained in a practice model that focuses on disease. (Shi and Singh 2015) Themes Relevance

This work has implications for the future if looked at further, beta tested, and the outcomes analyzed in detail. With the decline of primary care physicians, the rise in health care costs, and increased focus on quality and access, more providers training and offering services at a lower cost will help with overall supply and demand. In 2008, a 2 year initiative was developed to transform the nursing profession. (Shi and Singh 2015) All recommendations increased the scope, level of professional education, and responsibility of nurses. This, coupled with the fact that nurse practitioners focus on health promotion and function at a lower cost can help with the shortage of providers fast approaching.

Physician assistants are already filling in many of gaps left in the primary care delivery system both in general practice and specialty services. Advancing programs that help elevate them to more proactive roles in overall care provision will be an important aspect to lessening the shortage. The more providers of primary care, the greater access for individuals who will help with mal-distribution. It will also enhance the quality of care in that those things that nurses can excel in and physician assistants can begin to focus on specialty areas. The cost of health care is often in direct correlation to the level of specialty the doctor has. By creating more access at lower levels, this will help spread cost. The provision and focus on preventive care and health promotion over time will increase the quality. The initiatives could then help diminish the high costs associated with lack of health care over time. INFLUENCE ON HEALTHCARE FOR THE FUTURE

This article was chosen because of its high potential to impact future models of care delivery and high relevance to the field of long-term care. Currently, physicians focused on gerontology are in short supply. Any model that will assist in moving away from care that is dominated by the PCP has to be considered. In long-term care, which the delivery of remains a challenge, nurses are already the primary providers of service. They are managing care coordination, family dynamics, funding sources, pharmacologic services, end of life issues, and the day to day assessments of changes. All while knowing the individual well enough, to understand when a change has occurred that is significant. That is patient-centered care and a good basis for patient-centered medical homes. Nurse managed care centers would help keep costs lower for LTC patients. Patient Centered Medical homes would be able to assist those who are more medically complex and also, help keep costs lower by ensuring people can stay at home longer. THINGS TO THINK ABOUT

In reviewing the article, it seems easy to shift the model. There are many students entering the nursing profession, so just provide more incentives for advanced education. However, it is not that simple. There are waiting lists for nursing school, let alone advanced practice nurses. Scope of practice laws in most states could hinder the growth of both physician assistants and nurse practitioners alleviating some of the health care needs. Changing regulations, just this month, limit the scope of practice for an LPN and create more needs for RN in the health care field and again, schools are needing more instructors to offer more classes.

Also, other professions could be impacted by these new models of care. How would these changes related to Certified Nursing Assistants, Dietary Aides, and therapists? Would it change their roles and scope of service? Would the payment follow the person and would insurance companies embrace these new models of care delivery? Would these new models increase patient-centeredness and more face to face time with their doctors or less time? On the surface, a new model of delivery seems like an easy solution.

However, after digging deeper all these questions are raised in my mind even as my own organization explores a medical home model in Iowa. The hope had been that this article would give more answers around how these models can work, versus raise more questions about their success or impact. Overall these models will become more prevalent in the next 5-10 years as we are all challenged to find alternative cost effective ways to provide the same care we do now, how we will bridge the gap from where we are now to where we need to go remains to be seen. It will take innovative providers, collaborative partners, and organizations willing to step outside their comfort zone with new models that will lead the charge.

REFERENCES
Auerbach, D. I., Chen, P. G., Friedberg, M. W., Reid, R., Lau, C., Buerhaus, P. I., et al. (2013). Nurse-Managed Health Centers and Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage. Health Affairs, 32(11), 1933-1941.

Shi, L., & Singh, D. A. (2015). Delivering Health Care in America: A Systems Approach (6th ed.). Boston: Jones and Bartlett.