Nurse Practitioner Clinics and Mobile FNP Entrepreneurship

Introduction

There are over 125,000 nurse practitioners (NPs) in the U.S., according to estimates from the American Academy of Nurse Practitioners (AANP). Compared to physician assistants, NPs enjoy greater autonomy and responsibility, and have been increasingly assuming roles in administrative leadership, alongside their conventional patient-care duties at clinics and hospitals. However, owing to the thorough knowledge required to succeed within private practice settings, NPs often establish independent practices only after many years of experience at healthcare centers such as hospitals, in the role of salaried NPs (Furlow, 2011).

According to Tine Hansen-Turton, Chief Executive of the National Nursing Centers Consortium (NNCC), substantial growth has been observed in nurse-run health clinics both before and after the implementation of the Affordable Care Act (ACA). She reports that the number of nurse-run clinics across the nation has grown to five hundred, and this figure is expected to rise as providers seek more cost-effective means of delivering healthcare (Toner, 2014). Furthermore, since nurses' salaries are lower than physicians', significant savings can be achieved. Nurse practitioners also do not hesitate to provide healthcare in areas that are medically underserved, such as remote rural localities. Nevertheless, NPs face significant challenges. While they are authorized to open offices in medically underserved areas, their clinic cannot be more than seventy-five miles from their supervising physician's base. Additionally, those physicians must visit the nurse's clinic no less than once every ten days and review a minimum of 10% of the total cases the NPs handle.

NP programs are being implemented to fill gaps in underserved urban and rural regions where primary care is otherwise inaccessible (Helseth, 2010). NPs can handle between 80% and 90% of the primary care problems typically managed by physicians. Just as a primary care doctor refers a patient to a specialist when advanced care is needed, an NP refers patients to a physician when a problem falls outside his or her scope of practice. An enormous demand exists for developing this role to address disease prevention and health promotion needs, as well as to provide underserved populations with evidence-based healthcare. Elderly and homeless individuals without access to transportation for visiting hospitals are cared for by NPs, particularly by mobile family nurse practitioners (FNPs). The nursing profession is increasing in both depth and breadth. While some physicians view the emerging trend of mobile FNPs and nurse-owned facilities as a threat to their profession, those who benefit from such services do not share this concern. A broader debate has emerged over whether NPs threaten the future of medical care, as a global expansion in the number of NPs continues.

The Case for Healthcare Reform and NP Expansion

Universal healthcare access, affordable prices, holistic coverage, and superior quality care are the four pillars of U.S. healthcare reform. The nation's present healthcare system has performed well on the quality dimension, passably on coverage, and poorly on cost and access. Continuously rising co-payments and premiums have rendered health coverage unaffordable for many families. Approximately 40 million U.S. citizens lack adequate health coverage. Even those who are insured often receive insufficient long-term and preventive care services, yet the nation's annual healthcare spending approaches a trillion dollars (Aiken & Sage, 1992, p. 187). Healthcare service utilization remains exceedingly wasteful, pointing to a need for reducing healthcare delivery expenditures.

The U.S. has an excess of surgical and medical subspecialists, but an inadequate number of primary care providers. Furthermore, shortages of healthcare providers persist in several areas across the country. While 240 doctors exist per 100,000 individuals in the U.S. overall, 23% of the population resides in rural localities with an average of just 67 doctors per 100,000 individuals (Aiken & Sage, 1992, p. 189). The health status of ethnic and racial minorities is worse than that of the majority population, partly due to the absence of efficient healthcare services (Aiken & Sage, 1992, p. 190). Present medical education patterns disfavor many of the skills most important for a reformed healthcare system (Aiken & Sage, 1992, p. 191). Accordingly, Aiken and Sage support expanded nursing practice, noting that nursing education is founded on a comprehensive approach to disease prevention and health, in contrast to the physician-training model, which places emphasis on technology and specialization.

In the U.S., nurses constitute the largest healthcare provider group and form the first link to patients in many healthcare settings. In recent decades, the number of licensed registered nurses (RNs) has grown steadily to approximately 2.9 million. This growth has been accompanied by a rise in the competence and numbers of highly qualified advanced practice registered nurses (APRNs). APRNs are nursing professionals with at least a postgraduate nursing degree, certified by specialty nursing or professional institutions, and authorized to deliver patient care in line with their specialty and state nursing practice scope regulations (Naylor & Kurtzman, 2010, p. 893). The increasing proportion of aged and chronically ill individuals intensifies concerns about workforce adequacy and persistent quality gaps. Questions regarding the value of the primary healthcare system — as measured by U.S. performance on economic indicators, patient experience dimensions, and health outcomes — have been raised frequently, particularly in comparison with other developed nations.

NP Outcomes Compared to Physician-Delivered Care

The research findings of Naylor and Kurtzman (2010, p. 895) are corroborated by three randomized clinical trials and two secondary analyses based on those trials. The findings are further supported by at least fourteen additional descriptive studies comparing primary care delivered by physicians and NPs. Care provided by NPs equaled that provided by physicians. In fact, in some studies, NPs delivered better care on selected measures compared to physicians. Uniformly across all studies, no significant group differences were found among NPs with respect to patient health status, prescribing behavior, or treatment practices. Moreover, NPs consistently produced better results on the following measures: consultation time, patient follow-up, screening, counseling and assessment, and patient satisfaction.

Mobile FNPs and Services for Vulnerable Populations

The homeless population is identified as one of the most vulnerable groups relying extensively on healthcare provider services, and contributes significantly to the healthcare system burden. Patients with limited resources and unstable housing situations are associated with a greater likelihood of re-hospitalization. Service disparity with respect to this group gives rise to hopelessness, helplessness, and a sense of dehumanization. The homeless are frequently stigmatized and regarded as unproductive burdens on society, depending on the state for their overall care. High-risk healthcare system users contribute to the phenomenon known as "revolving door syndrome" (Fraino, 2015, p. 39). Mobile healthcare team implementation is aimed at providing continued and extended health services after hospital discharge to improve patients' chances of living successfully and independently within their communities. Opportunity Village Mobile Health is a pilot initiative created to provide mobile healthcare services to homeless individuals in Marin County, California, during the transition from hospital to community settings.

Post's 2007 report, published with the support of the U.S. Department of Health and Human Services (HHS), outlined the experiences of thirty-three Healthcare for the Homeless grant recipients and subcontractors regarding the adoption of mobile outreach to extend healthcare services to homeless individuals across 24 states. The report is primarily directed at direct health service providers and program administrators currently involved in mobile healthcare outreach, as well as individuals interested in developing or participating in programs of this kind.

The report focuses on the use of outreach vehicles to provide various healthcare services to individuals lacking stable housing. A total of seven healthcare workers ride the program's medical van: an NP, two front-desk medical or clinical office assistants, one outreach RN, one licensed practical nurse, one social worker or care advocate responsible for benefits support and referrals, and one outreach specialist engaged in the field work of locating homeless clients. Eighty-two percent of participants identified the following two elements as critical to mobile health outreach's success: forming partnerships with community organizations and selecting appropriate service sites where homeless individuals congregate. Personnel effectiveness in building trusting relationships with clients was cited as the second critical factor (identified by 79% of participants).

A number of respondents stressed the importance of having an outreach worker or clinician who had been part of the mobile program for an extended period. Nearly half (45%) of participants cited outreach — taking healthcare to the homeless rather than requiring them to travel to facilities — and the mobile unit's recognizable and welcoming appearance as key to increasing health services access for underserved populations. Finally, 39% attributed program success to the unit's sound reputation among community service personnel and the homeless, built over several years. Information technology for facilitating outcome monitoring, care continuity, and linkage to holistic services was also emphasized as a key element of program success by multiple participants.

Conclusion

A number of states mandate that nurse practitioners participate in collaborative arrangements with local physicians in order to establish private practices. Their scope of practice is governed at the state level, as no federal laws or standards exist regarding NP practice. Although practice scope laws differ from state to state, every state limits NPs to practicing only in those specialty areas in which they are certified and credentialed (Furlow, 2011). The evidence reviewed in this paper strongly supports expanding the NP model as a viable, cost-effective solution for addressing primary care shortages, improving access for underserved populations, and delivering patient-centered care of comparable or superior quality to traditional physician-delivered services.

References

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