Ahead of the Curve on Primary Care Staffing

As healthcare moves toward a value-based landscape, many organizations are rethinking the roles of nurse practitioners and physician assistants. Can advanced care practitioners solve the low-cost, high-value care paradox?

Recent research into high-performing healthcare organizations on the athenahealth network shows that many organizations that excel on quality metrics use advanced care practitioners to handle key parts of their operations.
But how will that transformation in healthcare delivery affect the quality of care? An answer might lie in the long experience of federally qualified health centers.
New research from athenahealth and the Robert Wood Johnson Foundation finds that in community health centers that care for high-risk patient populations, advanced care practitioners are already delivering the majority of patient care. Leaders of those systems say a staffing program driven by necessity and cost offers unique benefits for those patients — and new possibilities for all healthcare systems.
Researchers from athenahealth and the Robert Wood Johnson Foundation analyzed patient costs and staffing patterns at 31 FQHCs since 2015. They found that NPs and PAs account for 51 percent of all patient visits at federally qualified health centers serving distressed or isolated communities.
By contrast, 28 percent of visits are with nurse practitioners in other healthcare settings, according to data from the athenahealth network.
The analysis is based on 1.75 million visits from 470,000 patients to community health centers on the athenahealth network, compared to 87 million visits by 28 million patients to other primary care settings on the network.
The new data confirms historical patterns: Community health centers have always employed NPs, PAs, and allied health professionals to a greater degree than other health systems. The disparity is due, in part, to cost.
“FQHCs are really good at making a dollar out of 15 cents,” says Kemi Alli, M.D., CEO/CMO of Henry J. Austin Health Center of Trenton, New Jersey. Her organization, the largest non-hospital-based ambulatory care provider in the city, stretches its dollars by relying on nurse practitioners to deliver primary and preventive care — the bulk of encounters at health centers — at a far lower cost than physicians.
The NP difference
Yet the long alliance between nurse practitioners and FQHCs is due to more than finances — and may benefit patients in unique ways, says Alli.
“Nurse practitioners gravitate toward healthcare for underserved populations because it’s part of their culture, their mindset,” she says. “Nurses are the ones who do the hand-holding, who educate, who come in after the provider is gone and say, ‘Did you understand everything? Do you need help?’ And so many FQHC patients need that level of care.”
Many nurse practitioners grew up in the communities they serve, and so tend to have deep familiarity with the lives of their patients — what Troy Long, M.D., a population health specialist with Kaiser Permanente, calls “lived experience.” They share their patients’ culture and understand their challenges and strengths, he says.
And those qualities can help to keep patients engaged in their care to improve outcomes.
Andrew Van Wieren, M.D., an internist and medical director at Esperanza Health Centers, an FQHC in Chicago, agrees.
“Nurse practitioners do tend to be more empathetic and mission-oriented,” he says. Van Wieren also notes that, at his organization, nurse practitioners are often the most open to innovation.
“It’s our NPs who champion ACO participation and take the lead in participating in e-consults,” he says.
A symbiotic relationship
With few formal residency programs for nurse practitioners in the country, recent graduates of NP programs find that their minimal practical experience puts many clinical jobs out of reach — except at community health centers.
“For that first year or two,” says Alli, “there’s a symbiotic relationship. FQHCs need cost-effective providers, and nurse practitioners are willing to take a lower salary to get that clinical experience.”
And NPs get a breadth of experience in community health centers unavailable in most other settings.
“Unfortunately, our patients are more complex, sicker, and have higher needs,” says Alli. “It’s a good environment to learn in because you see things you might not see otherwise.”
Working with — and instead of — physicians
The widely-reported shortage of primary care physicians fills rural clinics with NPs and PAs. Forrest Olson, former COO of an FQHC — the Southern Illinois Healthcare Foundation — and athenahealth’s director of professional services, has found state legislators to be key drivers of the trend by authorizing expanded scopes of care for advanced care practitioners.
“Health centers tend to be well-connected to legislators. And they leverage those relationships to find ways to provide care in communities where it is difficult to keep a physician,” Olson says. “I had a few sites in very rural southwestern New Mexico that were PA-led clinics. Without a legislative dispensation, we would not have been able to provide continuous service in those communities.”
At urban Henry J. Austin Health Center, however, nurse practitioners partner with physicians, often sharing the same office, but each with their own panel of patients. That staffing model increases access to care for patients while reducing the risk of burnout for physicians. And, if a patient needs additional services beyond the scope of a nurse practitioner’s license, the physician partner will step in. Yet even Henry J. Austin is experimenting with an NP-only site, launched in collaboration with a local nursing program.
That willingness to experiment has been a hallmark of FQHC care since the designation was created in the 1960s. To provide quality care to high-risk populations — while facing limited budgets — community health centers have pioneered innovations such as mobile health clinics and the use of community health workers.
“FQHCs can teach all healthcare organizations more about the ways in which non-physicians can be used in outpatient care,” says Olson. 
Gale Pryor is a senior writer for athenaInsight. Data analysis by Anna Zink. Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. 

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