Thomas Sinsky, MD, a primary care internist in Iowa, was burning out. The complexity and intensity of work required for each patient seemed to grow exponentially over the years. The demands of managing prevention, acute and chronic illnesses, phone calls, emails, faxes, prescriptions, forms, and quality measures left him exhausted and unsatisfied.
Fortunately, working along with his wife, a fellow internist, and their nurses, they were able to transform their practice into a team-based care model. He now works with 3 registered nurses who manage all preventive care, conduct initial assessments that include psychosocial aspects of patients’ lives, share the findings with him during his visits with patients, follow up with treatment plans, coordinate care for complex patients, and provide health teaching and counseling to engage patients in better managing their chronic conditions.
“I love my work now. I’m able to actually see more patients and spend more time with them on issues that matter and require my expertise,” noted Sinsky at a June 2016 Josiah Macy Jr. Foundation invitational conference, which served as the basis for a new report, Registered Nurses: Partners in Transforming Primary Care (I was cochair of the conference planning committee). “I provide the medical decision making and the therapeutic plan and the [registered nurse] is the leader of the team when it comes to operationalizing the plan and managing the patients’ care.”
This theme was repeated throughout the conference, held in partnership with the American Academy of Nursing. An interprofessional group of participants discussed the challenges to more widespread use of registered nurses in primary care. (The focus was not on advanced practice registered nurses, such as nurse practitioners, except as primary care practitioners who need to redesign their own practices.)
The executive summary was published in September and includes the group’s recommendations. A full report that includes commissioned papers will be published at the end of 2016.
Challenges and Opportunities
The imperative to transform primary care is increasingly obvious, given the aging population and increasing rates of obesity and chronic illnesses. The Affordable Care Act (ACA) has boosted the demand for primary care by providing coverage for 20 million previously uninsured people in the United States. In addition, in an effort to contain the rate of health care expenditures, the ACA includes financial mechanisms to support health promotion and enhance chronic care management. But a shortage of primary care practitioners, including physicians, complicates successfully addressing these challenges.
Some primary care practices already make use of registered nurses, but often only for triaging and managing prescription renewals and emails. Instead, the Macy report calls for registered nurses in primary care to help patients better manage their chronic illnesses through teaching and coaching patients for behavior change, managing complex care teams to improve clinical and financial outcomes, and coordinating care for patients requiring complex care, including those with behavioral health problems.
Thomas Bodenheimer, MD, and Laurie Bauer, RN, MSPH, of the University of California, San Francisco, have argued that well-prepared registered nurses could partner with physicians to manage a panel of patients with chronic illnesses, including adjusting medications through standing orders as permitted by state law. The participants at the Macy conference concurred.
But using registered nurses in the transformation of primary care is challenging for a number of reasons.
First, only about 4% of schools of nursing are preparing registered nurses for primary care. One of the Macy conference’s commissioned papers by Danuta Wojnar, PhD, MN, MED, of Seattle University in Washington, and Ellen-Marie Whelan, PhD, RN, of the Centers for Medicare & Medicaid Services, reported on a survey of schools of nursing and found that, of the 529 responses, 77% understand the need to teach primary care but admit doing so to a limited degree. Others intentionally omit primary care content because they believe that undergraduate programs should focus on acute care. Furthermore, there is a lack of good role models for clinical practicums in primary care.
The Macy report calls for schools of nursing to increase the breadth and depth of their curricula and practicums in primary care. This will require retooling faculty who have been teaching in other clinical areas, identifying and partnering with exemplary primary care practices, and working with health systems to retrain practicing registered nurses to move to primary care or enhance the roles they already play in this setting.
Second, if schools of nursing increase their focus on primary care, will the jobs be there? Primary care practices must reevaluate their skill mix and rethink team roles in ways that can incorporate registered nurses beyond simply triaging or managing prescription refills and emails. This would require that all team members practice to the top of their education, training, and scope of practice. This may in turn require changes to scope-of-practice laws and regulations to permit nurses to practice by protocols and standing orders.
It also requires payers to develop payment models that cover all team members for good outcomes, such as reduced hospital readmissions, emergency room visits, and well-controlled hemoglobin A1c levels among patients with diabetes. For example, bundled payments permit practices to use registered nurses to make a home visit to help families identify and reduce home triggers for the child with persistent asthma.
The Macy conferees noted that some physicians say they can’t afford to hire registered nurses, particularly in practices with thin financial margins. But registered nurses can be paid for some aspects of an enhanced role now, and as value-based payment models spread, the outcomes that they can produce will reap financial benefits to the practice. Sinsky, who serves on a joint initiative of the American Board of Internal Medicine Foundation and the American Academy of Nursing Primary Care, says that enhancing their role in his practice has improved patient outcomes and the salaries of the 3 nurses are covered by the increased productivity of the practice: more patients can be seen and at a higher complexity level for the visits. He can focus on using his knowledge and skills in the best ways possible. For example, instead of doing the medication reconciliation himself, the registered nurses do it. He’s practicing at the top of his education and training and loves it.
As noted in the Macy report, transforming primary care will require the leaders of nursing and medical schools, primary care practices, health care organizations, and policy makers to make it a priority, including creating enhanced roles for registered nurses. Without visionary and vocal leadership, the transformation will not happen.
It’s no longer enough to simply talk about the importance of primary care. We must build a workforce that can help us to recreate a primary care system that advances the nation’s ability to meet the Quadruple Aim: improve the health of the population, the patient’s experience with care, and the clinician’s work satisfaction, while reducing health care costs.
Registered nurses are key to both capacity building and the transformation of primary care practice. The Macy recommendations provide us with the road map for this important journey.
About the author: Diana J. Mason, PhD, RN, Professor Emerita and Co-Director, Center for Health, Media & Policy at Hunter College, City University of New York; and Senior Policy Service Professor, George Washington University School of Nursing. She is the immediate past president of the American Academy of Nursing.
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