Registered Nurses: Partners in Transforming Primary Care

Chaired by

Thomas Bodenheimer, MD, MPH and Diana Mason, PhD, RN, FAAN

June 2016 Atlanta, Georgia

March 2017

Registered Nurses: Partners in

Transforming Primary Care

Proceedings of a conference on Preparing

Registered Nurses for Enhanced Roles in Primary Care

ISBN# 978-0-914362-51-7

REGISTERED NURSES: PARTNERS IN TRANSFORMING PRIMARY CARE BODENHEIMER AND MASON

This monograph is in the public domain and may be reproduced or copied without permission.

Citation, however, is appreciated.

Bodenheimer, T & Mason, D. Registered Nurses: Partners in Transforming Primary Care.

Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June 2016;

New York: Josiah Macy Jr. Foundation; 2017

All photos by Tony Benner.

Accessible at: www.macyfoundation.org

Registered Nurses:

Partners in Transforming

Primary Care

Proceedings of a conference on Preparing

Registered Nurses for Enhanced Roles in Primary Care

Thomas Bodenheimer, MD, MPH and

Diana Mason, PhD, RN, FAAN

Atlanta, Georgia June 2016

Edited by Teri Larson

Published by Josiah Macy Jr. Foundation

44 East 64th Street, New York, NY 10065

www.macyfoundation.org

March 2017

CONTENTS

Preface ......................................................................... 7

Introduction ..................................................................11

Conference Agenda ........................................................14

Conference Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Conference Conclusions and Recommendations .....................23

Primary Care Exemplar

West County Health Centers, Inc. in California .......................45

Primary Care Exemplar

Community Health Center, Inc. in Connecticut .......................48

Primary Care Exemplar

Clinica Family Health in Colorado. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Primary Care Exemplar

Medical Associates Clinic in Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Commissioned Paper

The Future of Primary Care: Enhancing the

Registered Nurse Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Commissioned Paper

Registered Nurses in Primary Care: Strategies that Support

Practice at the Full Scope of the Registered Nurse License ........89

Commissioned Paper

Expanding the Role of Registered Nurses in Primary Care:

A Business Case Analysis .................................................113

Commissioned Paper

Preparing Nursing Students for Enhanced Roles

in Primary Care: The Current State of Pre-Licensure

and RN-to-BSN Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141

Highlights from the Conference Discussion . . . . . . . . . . . . . . . . . . . . . . . . . .173

Selected Bibliography .................................................... 207

Biographies of Participants ..............................................211

PREFACE

GEORGE E. THIBAULT, MD

The 2016 Macy Conference, Preparing Registered Nurses for Enhanced Roles in

Primary Care, represents the intersection of three important Macy Foundation

themes. First, we have a long-standing interest in preparing health professionals for

careers in primary care dating back to our 2010 Macy Conference, Who Will Provide

Primary Care and How Will They be Trained?

The preparation of an appropriately

sized and skilled primary care workforce is critical to the success of a reformed

healthcare system that better meets the public’s needs.

Second, we have had a long-standing interest in improving nursing education to

prepare nurses for leadership roles in a reformed healthcare system. This has been

expressed by our support for interprofessional education

and our promotion of

the careers of nursing educators.

This Macy Foundation theme also is very closely

aligned with the recommendations of the Institute of Medicine’s Future of Nursing:

Leading Change, Advancing Health

report and the follow up National Academy of

Medicine study of the impact of the report.

Third, we have been very interested in working at the intersection of healthcare

delivery reform and health professions education reform, believing that the close

alignment of education and delivery reform is absolutely essential to achieve the

common goal of both education and delivery—that is, better health of the public

The idea for this conference was brought to us by the leadership of the American

Academy of Nursing, and we will be partnering with the Academy in disseminating

the recommendations to the nursing education community and the primary care

practice community.

The commissioned papers and the exemplar practice descriptions in this report

make the case for change and show that these changes are achievable. But to make

these enhanced roles for registered nurses more universal we will need to make

progress in all six domains of the conference recommendations:

1. Changing the cultures in both nursing schools and practices to place greater

value on primary care and the role of nurses in it.

2. Redesigning practices to make full use of the expertise of nurses.

3. Rebalancing nursing education to elevate primary care content.

4. Promoting the career development of nurses in primary care.

5. Developing primary care expertise in nursing school faculty.

6. Increasing opportunities for interprofessional education and teamwork

development in both education and practice.

The conferees felt strongly that there is great urgency in achieving all of these

recommendations not only to meet patient needs, but also to enhance the

professional satisfaction of nurses and all clinicians in primary care.

This conference was a great success because of the experience, enthusiasm, and

engagement of all the conferees. We had an outstanding planning committee that

provided oversight for the commissioned papers, conference planning and execution,

and the writing of the recommendations. And we had extraordinary leadership

throughout the process from Diana Mason and Tom Bodenheimer. None of this

would have happened without the meticulous administrative support provided by

Yasmine Legendre.

I am proud that the Macy Foundation has been able to make this contribution to

nursing education reform and primary care transformation.

George E. Thibault, MD

President, Josiah Macy Jr. Foundation

1 Cronenwett L, Dzau V, conference chairs. Who Will Provide Primary Care and How Will They be Trained? New York, NY:

Josiah Macy Jr. Foundation; 2010.

2 Josiah Macy Jr. Foundation. Conference on Interprofessional Education. New York, NY: Josiah Macy Jr. Foundation;

2012.

3 The Macy Faculty Scholars Program. http://macyfoundation.org/macy-scholars.

4 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National

Academies Press; 2011.

5 National Academies of Sciences, Engineering, and Medicine. Assessing Progress on the Institute of Medicine Report

The Future of Nursing. Washington, DC: The National Academies Press; 2016.

6 Cox M, Naylor M, conference chairs. Transforming Patient Care: Aligning Interprofessional Education with Clinical

Practice Redesign. New York, NY: Josiah Macy Jr. Foundation; 2013.

INTRODUCTION

For primary care in the United States, it is the worst of times and the best of

times. The gap is growing between the population’s need for primary care and

the capacity of primary care to meet that need. Soon, the number of retiring

primary care physicians will exceed the number of primary care physicians entering

the workforce.

The panel size of the average primary care physician is too large

to allow for excellent acute, chronic, and preventive care. Physician burnout is

widespread and increasing.

Yet a renewed enthusiasm and spirit of innovation can be found in primary care

practices across the country. And nurses—nurse practitioners and registered nurses

(RNs)—are poised to rescue primary care.

The number of nurse practitioners entering the workforce each year has

mushroomed from 6,600 in 2003 to 20,000 in 2015. Nurse practitioners will

increasingly be the primary care practitioners of the future. Of the approximately

222,000 nurse practitioners, 83.4% are certiﬁed in an area of primary care.

Yet the

ratio of primary care practitioners (including physicians, nurse practitioners, and

physician assistants) to the population will still decline. Thus other professionals will

be needed to care for the growing number of US adults with chronic conditions, as

well as to focus on health promotion and address social determinants of health.

Registered nurses, the largest health profession in the nation with over 3.5 million

members, are ideally suited to provide the bulk of care for people with chronic

illnesses. In primary care, RNs may assume at least four responsibilities: 1) Engaging

patients with chronic conditions in behavior change and adjusting medications

according to practitioner-written protocols; 2) Leading teams to improve the care

and reduce the costs of high-need, high-cost patients; 3) Coordinating the care

THOMAS BODENHEIMER, MD, MPH

DIANA MASON, PhD, RN, FAAN

CONFERENCE CO-CHAIRS

of chronically ill patients between the primary care home and the surrounding

healthcare neighborhood; and 4) Promoting population health, including working

with communities to create healthier spaces for people to live, work, learn, and play.

The number of RNs available to function in these enhanced primary care roles

should be plentiful; from 2001 to 2014, the number of new nurses taking the NCLEX

RN licensing exam more than doubled, from almost 69,000 to 158,000 per year.

Already, 43% of US physicians are working with nurse care managers for patients

with chronic conditions.

And studies clearly show that RNs are qualiﬁed to perform

these enhanced roles. For example, in a randomized controlled trial, diabetic

patients with elevated blood pressures cared for by RN care managers were more

likely to reach their blood pressure goals than patients managed by physicians

alone.

Serious challenges face the widespread incorporation of RNs into these primary

care roles. Public and private insurers are only beginning to pay for services

performed by RNs; most RN work is viewed by practice administrators as an

expense but not as a source of revenues. State boards of nursing are ambivalent

about granting RNs authority to perform the medication management that is a key

part of chronic disease management and some prohibit the use of standing orders

developed by primary care practitioners for RNs to use when following a panel of

patients.

The 2016 Macy Foundation conference on preparing RNs for enhanced roles in

primary care addresses perhaps the most difﬁcult challenge: the paucity of primary

care content in most nursing schools, including both didactic content and clinical

experiences. RN education continues to emphasize in-patient hospital nursing and

many nursing faculty are unfamiliar with primary care nursing. Some faculty and

practicing RNs continue to recommend that new nurses spend a minimum of a year

on a hospital medical-surgical unit before moving into community-based practices,

even if the new nurse has no interest in such a position.

This is not a surprise given the nation’s overinvestment in acute care, while failing

to develop a robust primary care system. Nurses responded to the nation’s call

for expanding acute care with the Hill-Burton Act of 1946 that provided funds for

building and expanding the nation’s hospitals. The failings of this downstream

system of care, however, have become evident as numerous studies document

that the US spends more on health care than other peer countries but is last or

near-last on key indicators of health, such as maternal mortality.

6,7

It’s time for

nurses to partner with others to transform our healthcare system into one that

promotes the health of individuals, families, and communities, including preventing

and better managing chronic illnesses.

The Macy conference brought together leaders in nursing education and primary

care, working together to propose actionable recommendations for re-balancing

nursing education to encourage RNs to become leaders in primary care teams,

with the skills needed to improve the health of the American people. These

recommendations include developing partnerships with primary care practices to

develop and test expanded roles for RNs and all staff.

It will take all of us to push for this transformation. This report provides the

direction for doing so. We hope that you will join us in disseminating these

recommendations, using the report to trigger important conversations within and

among schools of nursing, primary care practices, healthcare systems, and other

organizations about how to rethink and redesign primary care with the help of the

nursing workforce. Our nation’s health is at stake.

Thomas Bodenheimer, MD, MPH

Conference Co-Chair

1 Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected

primary care physician shortages by 2035. Ann Fam Med 2015;13:107-114.

2 American Association of Nurse Practitioners. NP Fact Sheet. 2016. Available at https://www.aanp.org/all-about-nps/

np-fact-sheet.

3 Salsberg E. Recent trends in the nursing pipeline: BSNs continue to increase. Health Aff Blog April 9, 2015. Available

at http://healthaffairs.org/blog/2015/04/09/recent-trends-in-the-nursing-pipeline-us-educated-bsns-continue-to-

increase/

4 Bodenheimer T, Bauer L. Rethinking the primary care workforce: An expanded role for nurses. N Eng J Med 2016;

375:1015-1017.

5 Denver EA, Barnard M, Woolfson RG, Earle KA. Management of uncontrolled hypertension in a nurse-led clinic

compared with conventional care for patients with type 2 diabetes. Diabetes Care 2003;26:2256-2260.

6 Davis K, Stremikis K, Squires D, Shoen, C. Mirror, mirror on the wall: How the performance of the U.S. healthcare

system compares internationally. Commonwealth Fund: New York; 2014. Available at http://www.commonwealthfund.

org/~/media/ﬁles/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

7 National Research Council. U.S. Health in International Perspective: Shorter Lives, Poorer Health. National Academies

of Science: Washington, DC; 2013. Available at https://www.nap.edu/catalog/13497/us-health-in-international-

perspective-shorter-lives-poorer-health.

Diana J. Mason, PhD, RN, FAAN

Conference Co-Chair

CONFERENCE AGENDA

WEDNESDAY, JUNE 15, EVENING

3:00 – 6:00 pm Registration

6:00 – 7:00 pm Welcome Reception

7:00 – 9:30 pm Dinner with Introduction of Conferees

THURSDAY, JUNE 16, MORNING

7:00 – 7:30 am Breakfast

7:30 – 12:30 pm Session 1

7:30 – 8:15 am Working breakfast with opening remarks

George Thibault, Thomas Bodenheimer, Diana Mason

8:15 – 8:50 am Discussion of themes from commissioned paper

The Future of Primary Care: Enhancing the Registered Nurse Role

Thomas Bodenheimer

Moderators: Joyce Pulcini, Steve Schoenbaum

8:50 – 9:25 am Discussion of themes from commissioned paper

Registered Nurses in Primary Care: Strategies that Support Practice

at the Full Scope of the Registered Nurse License

Margaret Flinter

Moderator: Debra Barksdale

9:25 – 9:55 am Discussion of themes from commissioned paper

Expanding the Role of Registered Nurses in Primary Care:

A Business Case Analysis

Jack Needleman

Moderators: Bobbie Berkowitz, Ellen-Marie Whelan

9:55 – 10:25 am Discussion of themes from commissioned paper

Preparing Nursing Students for Enhanced Roles in Primary Care:

The Current State of Pre-Licensure and RN-to-BSN Education

Danuta Wojnar, Ellen-Marie Whelan

Moderator: Beth Ann Swan

10:25 – 10:40 am Break

10:40 – 12:15 pm Plenary discussion: What are key components of the enhanced

role of the RN in tomorrow’s primary care practices?

Moderators: Thomas Bodenheimer, Diana Mason

12:15 – 12:30 pm Charge to breakout groups

THURSDAY, JUNE 16, AFTERNOON

12:30 – 1:30 pm Lunch

1:30 – 5:30 pm Session 2

1:30 – 3:00 pm Breakout Sessions

Breakout 1

How should pre-licensure and RN-to-BSN nursing

education programs revise their curricula to better

prepare their graduates for careers in primary care

nursing?

Moderator: Debra Barksdale

Breakout 2

How are existing RNs, who want to change their careers

to become primary care RNs or are already practicing in

primary care, prepared for this enhanced role now; how

could such professional development better prepare

existing RNs for enhanced roles in primary care (consider

potential barriers and facilitators); and what might the

curriculum look like?

Moderator: Beth Ann Swan

Breakout 3

What are the challenges/opportunities for education-

service interprofessional collaboration to build up

primary care practices that enable RNs and other

health professionals to work in effective and cohesive

teams?

Moderator: Bobbie Berkowitz

Breakout 4

What are the barriers/facilitators to changing nursing

education to place greater emphasis on primary care

nursing, and how might these be overcome?

Moderator: Joyce Pulcini

Breakout 5

What are the barriers/facilitators to changing primary

care practice to enhance the RN role, and how might

these be overcome?

Moderators: Ellen-Marie Whelan, Steve Schoenbaum

3:00 – 3:15 pm Break

3:15 – 5:00 pm Plenary Session

Report out from Breakout Groups

5:00 pm Adjourn

THURSDAY, JUNE 16, EVENING

7:00 – 9:30 pm Reception & Dinner at the Atlanta Botanical Garden

FRIDAY, JUNE 17, MORNING

7:00 – 7:30 am Breakfast

7:30 – 12:00 pm Session 3

7:30 – 8:30 am Working Breakfast, Brief recap of Day 1 and

Charge to Breakout Groups

Thomas Bodenheimer, Diana Mason

8:30 – 11:30 am Five Breakout Groups

Breakout 1

The practice environment: the role and use of

registered nurses in primary care.

Moderators: Joyce Pulcini, Ellen-Marie Whelan

Breakout 2

Pre-licensure education needed to prepare

registered nurses in primary care.

Moderator: Beth Ann Swan

Breakout 3

Professional development of registered nurses

for primary care.

Moderator: Bobbie Berkowitz

Breakout 4

IPE and team training.

Moderator: Steve Schoenbaum

Breakout 5

Faculty development and system changes.

Moderator: Debra Barksdale

11:30 – 12:00 pm Group Photo

FRIDAY, JUNE 17, AFTERNOON

12:00 – 1:00 am Lunch

1:00 – 5:00 pm Session 4

1:00 – 3:00 pm Plenary Session

Report out from Breakout Groups

Moderators: Thomas Bodenheimer, Diana Mason

3:00 – 3:15 pm Break

3:15 – 5:00 pm Response to reports from Breakout Groups and identiﬁcation of

missing themes and recommendations

Moderators: Thomas Bodenheimer, Diana Mason

5:00 pm Adjourn

FRIDAY, JUNE 17, EVENING

6:30 – 9:30 pm Reception & Dinner at Ray’s in the City

SATURDAY, JUNE 18, MORNING

7:00 – 8:00 am Breakfast

8:00 – 11:45 am Session 5

Conference Conclusions and Recommendations

George Thibault, Thomas Bodenheimer, Diana Mason

11:45 – 12:00 pm Summary Remarks

George Thibault

12:00 pm Adjourn

2020

CONFERENCE PARTICIPANTS

Carmen Alvarez,

PhD, RN, CRNP, CNM

Johns Hopkins University

Erica D. Arana,

DNP, RN, CNS, CNL, PHN

University of San Francisco

Cynthia C. Barginere,

DNP, RN, FACHE

Rush University College of Nursing

Debra J. Barksdale,

PhD, FNP-BC, CNE, FAANP, FAAN

Virginia Commonwealth University

Kenya V. Beard,

EdD, AGACNP-BC, NP-C, CNE, ANEF

CUNY School of Professional Studies

Judith G. Berg, MS, RN, FACHE

HealthImpact

Bobbie Berkowitz,

PhD, RN, NEA-BC, FAAN

Columbia University School of Nursing

Mary Beth Bigley,

DrPH, APRN, FAAN

Health Resources and Services

Administration

Thomas Bodenheimer, MD, MPH

University of California,

San Francisco School of Medicine

Janice G. Brewington,

PhD, RN, FAAN

National League for Nursing

Peter I. Buerhaus, PhD, RN, FAAN

Montana State University College of Nursing

Ellen H. Chen, MD

San Francisco Health Network

Marilyn P. Chow, PhD, RN, FAAN

Kaiser Permanente

Pamela F. Cipriano,

PhD, RN, NEA-BC, FAAN

American Nurses Association

Jason Cunningham, DO

West County Health Centers

Malia Davis, MSN, RN, ANP-C

Clinica Family Health Services

Margaret M. Flinter,

APRN, PhD, FAAN, FAANP, c-FNP

Community Health Center, Inc.

Erin Fraher, PhD, MPP

The University of North Carolina

at Chapel Hill

Robyn L. Golden, MA, LCSW

Rush University Medical College

Andrew Harmon, BS

Jefferson College of Nursing,

Thomas Jefferson University

Susan B. Hassmiller, PhD, RN, FAAN

Robert Wood Johnson Foundation

Laura Hieb, MBA, BSN, RN, NE-BC

Bellin Health System

Anne T. Jessie, DNP, RN

Carilion Clinic

Gerri Lamb, PhD, RN, FAAN

Arizona State University

Diana J. Mason, PhD, RN, FAAN*

The George Washington University

School of Nursing

Peter McMenamin, PhD

American Nurses Association

Storm L. Morgan, MSN, RN, MBA

US Department of Veterans Affairs

Andrew Morris-Singer, MD

Primary Care Progress

Mary D. Naylor, PhD, RN, FAAN

University of Pennsylvania School of Nursing

Jack Needleman, PhD, FAAN

University of California, Los Angeles

Fielding School of Public Health

Camille Prado, BS, RN

University of California, San Francisco

Joyce Pulcini,

PhD, RN, PNP-BC, FAANP, FAAN

The George Washington University

School of Nursing

Lisa Rivard, RN, CDE

Scripps Health and Neighborhood

Health Care Clinics

Sandra F. Ryan,

RN, MSN, CPNP, FCPP, FAANP, FAAN

Walmart

Stephen C. Schoenbaum, MD, MPH

Josiah Macy Jr. Foundation

Karla Silverman, MS, RN, CNM

Primary Care Development Corporation

Thomas A. Sinsky, MD

Medical Associates Clinic

Alice D. Smith, BSN, RN

Harvard Vanguard Medical Associates,

Atrius Health

Beth Ann Swan, PhD, CRNP, FAAN

Jefferson College of Nursing,

Thomas Jefferson University

George E. Thibault, MD

Josiah Macy Jr. Foundation

Donna Thompson, RN, MS

Access Community Health Network

Deborah Trautman, PhD, RN, FAAN

American Association of Colleges of Nursing

Ellen-Marie Whelan,

PhD, RN, CRNP, FAAN

Center for Medicaid and CHIP Services

Centers for Medicare and Medicaid

Innovation

Danuta M. Wojnar, PhD, RN, MED,

IBCLC, FAAN

Seattle University College of Nursing

STAFF

Peter Goodwin, MBA

Josiah Macy Jr. Foundation

Yasmine R. Legendre, MPA

Josiah Macy Jr. Foundation

Cheryl Sullivan, MSES

American Academy of Nursing

Ellen J. Witzkin

Josiah Macy Jr. Foundation

Teresa Cirillo

EMCVenues

Teri Larson

Teri Larson Consulting

*Planning Committee Member

REGISTERED NURSES:

PARTNERS IN TRANSFORMING PRIMARY CARE

CONFERENCE CONCLUSIONS

AND RECOMMENDATIONS

Primary care in the United States is in urgent need of transformation. The current

organization and capacity of our primary care enterprise are insufﬁcient to meet

the healthcare needs of the public. The 2010 Affordable Care Act (ACA), which

emphasizes the importance of primary care, has enabled millions more people to

seek care at a time when more than half of Americans have at least one chronic

condition and many have multiple illnesses and complex healthcare needs—trends

that will continue as the population ages. However, resources currently allocated

to primary care are inadequate. Strengthening the core of primary care service

delivery is key to achieving the Triple Aim: improved patient care experiences,

better population health outcomes, and lower healthcare costs.

These mounting pressures from external forces are shifting primary care toward

new practice models staffed by high-functioning, interprofessional teams. Teams

can increase access to care; improve the quality of care for chronic conditions; and

reduce burnout among primary care practitioners, including physicians, physician

assistants, and nurse practitioners. But this team-focused culture shift is nascent

and, without enough appropriately trained healthcare professionals, primary care

could falter under the increased demand.

Who can help alleviate the pressures on primary care? A tremendous, available

resource is the 3.7 million registered nurses (RNs)—who comprise the largest

licensed health profession in the nation. RNs are the ideal team members to help

expand primary care capacity, yet they have been woefully underutilized in primary

care settings. Practices that have deployed registered nurses in enhanced roles

have shown improved health outcomes, reduced costs, and enhanced patient

satisfaction.

Registered nurses, appropriately prepared and working to the full scope of their

licensure, can successfully implement and sustain patient-centered services for the

aging and increasingly complex primary care population. They can increase access

to care for all patients, and also assist in the management of patients with chronic

diseases—such as diabetes, hypertension, chronic obstructive pulmonary disease,

and substance abuse and mental health conditions—who require more services.

They also can help improve transitional care, as patients move between hospitals,

other care facilities, and home. Further, they can help improve patient engagement,

quality scores, and team collaboration using health assessments, patient education,

motivational interviewing, medication reconciliation, care planning, and more. This

can occur through RNs following a panel of patients as well as through nurse-led

individual and group visits.

While the large RN workforce has the potential to help meet the 21st century

demands facing primary care, a number of barriers must be overcome. First,

many RNs currently working in primary care spend much of their time on patient

triage, sorting out who needs to be seen immediately and who can wait. This is an

important function, but primary care practices need to balance RNs’ time between

traditional triage and the emerging chronic care management, care coordination,

and preventive care. Second, some state laws limit utilizing RNs to the full extent of

their education and training. Even when state law supports full practice authority,

healthcare organizations sometimes restrict RNs from practicing to the full extent of

their licensure.

Third, much of the work that RNs and other primary care team members currently

perform is not directly reimbursable under the traditional fee-for-service payment

model, meaning that new payment models are needed to facilitate the growth of

primary care teams that include RNs. Finally, and perhaps most importantly, many

RNs are not exposed consistently to the full range of primary care content in the

classroom or through instructional clinical experiences, which overwhelmingly focus

on inpatient and acute care. As a result, RNs may lack skills and competencies

essential to functioning effectively in primary care.

The signiﬁcance of these issues and their relevance to the mission of the Josiah

Macy Jr. Foundation prompted the Foundation to focus its annual conference on

the topic of Preparing Registered Nurses for Enhanced Roles in Primary Care. The

conference represented the intersection of three themes of importance to the

Foundation in its efforts to help reform health professions education: improving

primary care, preparing nurses for leadership roles, and linking education reform

and healthcare delivery transformation.

The conference generated actionable recommendations around the potential for

RNs to help meet the urgent needs of primary care. Participants at the two-and-a-

half-day working conference—held June 15–18, 2016 in Atlanta, Georgia—included

more than 40 leaders in primary care, representing academic nursing and medicine,

healthcare delivery organizations, professional nursing associations, healthcare

philanthropy, and more. Nursing students also were at the table.

“The forward momentum in primary care means we are moving in the right

direction, toward higher value care that is focused on improving the health of the

public,” said Macy Foundation President George Thibault, MD. “But we have a

long way to go. We simply can’t meet the primary care needs of the nation unless

registered nurses are part of the solution, and we must prepare them appropriately

and then use them for this role.”

CONTEXT FOR THE CONFERENCE

Nursing has its roots in primary health care. Florence Nightingale, widely

recognized as the 19th century founder of modern nursing, said: “Money would

be better spent in maintaining health in communities rather than building hospitals

to cure.” By the early 20th century, registered nurses were serving as autonomous

primary care providers, particularly in urban centers and rural communities where

the needs were greatest. In 1919, a nurse-run community health center regarded

the hospital as a “repair shop, necessary only where preventive medicine has

failed.”

Nursing, at its core, has a history of helping patients identify and improve their

psychosocial and health needs. Nursing education, in contrast to other health

professions education programs, includes a holistic approach to patients that

is not solely based on organ systems or body parts. Nursing science includes

an assessment of personal and familial health within a social and environmental

context, not just a focus on disease and treatments. This becomes even more

important as the role of primary care in the US health system expands to

acknowledge and address the role that social determinants of health play in

achieving improved health status.

By the mid-20th century, health care’s center of gravity shifted from homes and

communities to hospitals, and the nursing profession followed suit. Approximately,

60% of registered nurses work in hospitals, and nursing schools focus on the skills

needed for inpatient hospital care, with little attention paid to practice in primary

care settings. Yet the costs of hospital-based care are too high and the health of

Americans lags behind other developed nations. Today, the pendulum is swinging

back toward community-based primary care. Changes in nursing education,

regulations, and payment are critical to support and accelerate this shift.

The Institute of Medicine’s Future of Nursing

report, released in 2011, echoed

these themes: “[W]hile changes in the healthcare system will have profound

effects on all providers, this will be undoubtedly true for nurses. Traditional nursing

competencies, such as care management and coordination, patient education,

public health intervention, and transitional care, are likely to dominate in a reformed

healthcare system as it inevitably moves toward an emphasis on prevention and

management rather than acute [hospital] care.”

While signiﬁcant progress has been made on the Future of Nursing

recommendations concerning advanced practice nurses, particularly nurse

practitioners, comparatively little attention has been paid to the report’s

implications for RNs. The American Academy of Nursing approached the Macy

Foundation to raise the signiﬁcance of this issue, and the Foundation now hopes to

reignite the conversation on the enhanced role of registered nurses in transforming

primary care to meet the needs of the nation.

1 Institute of Medicine. 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, DC:

The National Academies Press.

CONFERENCE DISCUSSION

To create a baseline from which to launch the conference discussion, the Macy

Foundation commissioned four papers

on topics related to registered nurses and

primary care practice. Prior to the conference, participants read the commissioned

papers as well as other suggested articles, and on the ﬁrst day of the conference,

discussions centered on themes from these papers.

The ﬁrst paper, The Future of Primary Care: Enhancing the Registered Nurse Role

by Conference Co-chair Thomas Bodenheimer, MD, MPH, and his colleague, Laurie

Bauer, RN, MSPH, both of the University of California, San Francisco, described

how the transformation of primary care in the United States is creating “favorable

conditions” for growth in the number of RNs in primary care, particularly in larger

practices and community health centers.

The paper also elucidated the likely roles of primary care RNs as focused around

patients with chronic disease; patients with complex health needs and high

healthcare costs; and patients whose care must be coordinated across many

settings, including hospitals, skilled nursing facilities, ambulatory practices, and

private homes. Barriers to more RNs working in primary care include the scarcity

of nurses adequately prepared to perform primary care functions and payers not

reimbursing for work performed by some members of the primary care team,

including RNs.

Registered Nurses in Primary Care: Strategies that Support Practice at the Full Scope

of the Registered Nurse License was the second commissioned paper. It was written

by Margaret Flinter, APRN, PhD, FAAN, senior vice president and clinical director

for Community Health Center Inc. (CHCI); Mary Blankson, APRN, DNP, chief nursing

ofﬁcer for CHCI; and Maryjoan Ladden, APRN, PhD, FAAN, senior program ofﬁcer

at the Robert Wood Johnson Foundation. This paper posits that achieving “better,

safer, higher quality care that is satisfying to both patients and providers, and

affordable to individuals and society” will require us to “effectively use every bit of

human capital available in the primary healthcare system,” and presents a vision for

the “blue sky” future of primary care and the role of RNs.

In this future, instructional programs offered by nursing schools, health systems,

professional organizations, and others will help existing RNs transition their careers

to other settings, and will offer learners opportunities to specialize in primary care,

community health, or public health nursing, including the option to complete a

residency or similar clinical education program in community-based settings. In this

future, in which all patients are served by primary care teams, registered nurses

will take on prevention and health promotion activities, minor episodic and routine

chronic illness management, and complex care management in conjunction with

other team members. They also will possess skills in population management,

quality improvement, and team leadership; will provide counseling and care

services via telehealth; and will expand the reach of primary care into

the community.

The authors conclude by stating: “This blue sky state requires much more than

just changing educational preparation. It requires today’s leaders and providers

to reorganize today’s primary care practices and systems to accommodate a truly

collaborative model of team-based primary care.”

The third paper commissioned for the conference, Expanding the Role of Registered

Nurses in Primary Care: A Business Case Analysis, was written and presented by

Jack Needleman, PhD, FAAN, professor and chair of the department of health

policy and management at the University of California, Los Angeles Fielding School

of Public Health. The author describes new roles for RNs that achieve economic

gains by engaging their expertise and reducing demands on primary care

clinicians. These roles include RN co-visits; RN-only visits using standing orders;

and increased responsibilities for RNs in care coordination, telehealth, patient

education, and health coaching.

Through two case studies, the author describes how primary care practices

have ﬁnancially supported the expanded role of the RN. For example, in fee-for-

service settings, increases in billable services can help pay for RNs in these new

roles, while in capitated settings, additional RN-related costs can be offset by

reduced use of other services, such as emergency department visits and hospital

readmissions. Additional research is needed to examine the feasibility of these roles

under emerging value-based payment structures and solidify the business case,

but evidence suggests that increased engagement of RNs in caring for high-cost

patients with chronic conditions will pay for itself and improve care.

The fourth and ﬁnal commissioned paper discussed at the conference was

Preparing Nursing Students for Enhanced Roles in Primary Care: The Current State

of Pre-Licensure and RN-to-BSN Education by Danuta Wojnar, PhD, RN, FAAN,

professor and associate dean for undergraduate education at Seattle University

College of Nursing, and Ellen-Marie Whelan, PhD, RN, CRNP, FAAN, chief

population health ofﬁcer at the Center for Medicaid and CHIP Services. The authors

presented results from their survey examining primary care content in the curricula

of the more than 500 pre-licensure (entry-level associate, baccalaureate, or master’s

degree) and RN-to-BSN education programs that responded to the survey. Though

the authors acknowledged limitations regarding their ﬁndings, among survey

respondents, only about 20 programs offered a robust primary care curriculum.

Findings from the survey focused on factors that facilitate and inhibit the

implementation of primary care content in nursing curricula. Some of the factors

facilitating primary care’s inclusion in nursing schools are recognition of the

emerging shift toward primary care; visionary leadership and forward-thinking

faculty; increasing opportunities to learn with other health professions students;

and mandates from state nursing commissions. Factors inhibiting the inclusion of

primary care curricular content are lack of faculty buy-in and RN faculty preceptors;

logistical challenges coordinating with community-based teaching sites; students’

fear of not acquiring acute care skills; and the perception that primary care is not

considered a signiﬁcant content area on the National Council Licensure Examination

for RNs (NCLEX-RN).

During conference discussions, participants agreed that registered nurses are well

suited to both generalized and specialized roles within primary care. Examples

of generalized roles include managing the care of panels of patients with chronic

diseases, working with interprofessional teams to improve the care of patients with

complex healthcare needs, and managing transitional care for patients between

inpatient facilities, ambulatory care, and home care. Registered nurses who are

experts in diabetes, heart failure, asthma, or behavioral health, or who are focused

on populations such as children or women, might perform specialized roles. A body

of evidence regarding the contributions of nurses in such roles has demonstrated

improved health outcomes and reduced costs.

As discussions progressed, conferees also agreed that preparing registered nurses

to serve in expanded roles will require exposing learners to all types of nursing,

including caring for patients across their lifespans and across all kinds of settings,

from hospitals to community health centers and schools, from private homes to

homeless shelters. While RNs should not be limited to acute [hospital] care, neither

should they be limited to primary care. Instead, they should be encouraged to

explore a variety of practice options to determine the best ﬁt for their personal

and professional needs and interests. Expanding educational options for nursing

students, including the development of interprofessional, collaborative practice

opportunities in a variety of community-based clinical settings, will require strong

partnerships between leaders of academia and clinical practice.

Conferees also discussed how RNs can help address two other concerns that

permeate many healthcare organizations: insufﬁcient attention to eliminating

persistent disparities in care, which harm vulnerable populations; and overemphasis

on acute care while minimizing the social determinants of health. RNs trained

in culturally responsive care, including developing the knowledge and skills to

recognize and address implicit and explicit bias and racism, will be better prepared

to care for diverse patients and address population health.

Essential to all of this, the conferees agreed, is changing the culture of health care

in general, and nursing in particular, to place more value on primary care as a career

choice. Nursing leaders within both academia and practice environments must

assume responsibility for this culture change. In concert, primary care practitioners

must embrace enhanced roles for RNs in primary care. The Macy conferees agreed

that enhancing the role of RNs to serve as members of primary care teams will

not only improve patient care, but also help reduce burnout and increase job

satisfaction among all team members. Further, if primary care hopes to solve its

capacity problem in caring for the 21st century population, primary care practices

will need to attract RNs by empowering them to enjoy professionally rewarding

jobs—caring for patients, promoting health, preventing illness, and addressing

population health.

CONFERENCE THEMES

The second day of the conference built upon the discussion themes that

emerged during the ﬁrst day, and conferees broke into groups to begin crafting

recommendations in the following areas.

1. Changing the Healthcare Culture

2. Transforming the Practice Environment

3. Educating Nursing Students in Primary Care

4. Supporting the Primary Care Career Development of RNs

5. Developing Primary Care Expertise in Nursing School Faculty

6. Increasing Opportunities for Interprofessional Education

CONFERENCE RECOMMENDATIONS

Over the course of the second day, speciﬁc recommendations and supporting or

sub-recommendations were drafted in small groups and debated during plenary

sessions. On the third day, the draft recommendations were reviewed and reﬁned—a

process that continued via phone and email following the conference. As a group,

the conferees felt strongly that the following recommendations were urgently

needed and possible to achieve.

I. Leaders of nursing schools, primary care practices, and health systems

should actively facilitate culture change that elevates primary care in RN

education and practice.

II. Primary care practices should redesign their care models to utilize the skills

and expertise of RNs in meeting the healthcare needs of patients—and

payers and regulators should facilitate this redesign.

III. Nursing school leaders and faculty should elevate primary care content

in the education of pre-licensure and RN-to-BSN nursing students.

IV. Leaders of primary care practices and health systems should facilitate

lifelong education and professional development opportunities in primary

care and support practicing RNs in pursuing careers in primary care.

V. Academia and healthcare organizations should partner to support and

prepare nursing faculty to educate pre-licensure and RN-to-BSN students in

primary care knowledge, skills, and perspective.

VI. Leaders and faculty in nursing education and continuing education

programs should include interprofessional education and teamwork

in primary care nursing curricula.

RECOMMENDATION I

Changing the Healthcare Culture. Leaders of nursing schools, primary care

practices, and health systems should actively facilitate culture change that elevates

primary care in RN education and practice.

Changes in educational priorities and in the structure of primary care practices will

not happen without leadership from educational institutions, primary care practices,

and professional organizations. Their incentive to take on this leadership role

comes from evidence that these changes will result in better patient care, improved

utilization of resources, and enhanced professional satisfaction. The necessary

policy and payment reforms and broad community support will also require

leadership advocacy. In addition, while there is evidence of the value of RNs in

primary care practices, building a strong business case for their use will accelerate

the pace of change in both education and practice.

Actionable Recommendations

1. Leaders of all healthcare organizations should support a culture change

that reimagines primary care and the enhanced role of RNs. This culture

change should maintain academic rigor around the biomedical model

while increasing the emphasis on the family, social, environmental contexts

of health and the importance of interprofessional teamwork in achieving

better patient outcomes and greater professional satisfaction.

2. Leaders of nursing schools and practice sites should advocate and allocate

resources for a re-balancing of nursing education to give greater priority

to the teaching of primary care knowledge, skills, and attributes to pre-

licensure nursing students, to RNs considering transitioning to primary care

careers, and to the continuing professional development of primary care

RNs. This will mean providing more primary care clinical opportunities for

all pre-licensure nursing students, professional development opportunities

for RNs in primary care who want to take on enhanced roles, and continuing

education for practicing RNs contemplating a move into primary care.

3. Leaders of both educational and healthcare delivery systems should

promote the academic-community partnerships that will be necessary to

achieve the re-balancing of education and the higher visibility of primary

care. Nurses should be in meaningful leadership roles in these partnerships,

and the career development of nurses in these partnerships should be

supported. These academic-community partnerships should also include

patient, family, and community representation.

4. Leaders of both educational and healthcare delivery systems should work

with policy makers, payers, government agencies, large employers, and

community leaders to advocate for the changes necessary to support the

work outlined in this report.

5. Leaders of all stakeholder organizations should help disseminate these

recommendations, working with the American Academy of Nursing and the

Josiah Macy Jr. Foundation.

RECOMMENDATION II

Transforming the Practice Environment. Primary care practices should redesign

their care models to utilize the skills and expertise of RNs in meeting the healthcare

needs of patients—and payers and regulators should facilitate this redesign.

Patient quality outcomes and the abilities of practices to build capacity can be

improved using enhanced RN roles, but government and private payers must

provide ﬁnancial support for building primary care capacity. In addition, the

practice environment must value enhanced RN roles and design care delivery and

payment models to make best use of RNs’ skills and competencies. Doing so will

improve access, outcomes, care coordination, and satisfaction.

Some best practices in the optimal deployment of RNs in primary care already

exist. Exemplary primary care practices

are using RNs to begin the appointments,

take histories, engage patients, and set the stage for long-term relationships—

with a primary care practitioner (PCP) coming in near the end of a visit to perform

medical management. Others are utilizing co-visits with RNs and PCPs working

side-by-side in the patient encounter. In these practices, an RN takes the lead role

in patient engagement, education, and activation, and uses data to inform practice.

The nurse also may take the lead on pre-visit planning and follow up after the visit,

in collaboration with the PCP, as well in transitional care and disease management.

In most documented cases, relying on RNs in these ways has enabled primary care

practices to increase their volume and revenues to the extent that, at a minimum,

the RN’s salary is offset.

Actionable Recommendations

1. Primary care practices should evaluate the skill mix of current team

members to ensure that their contributions are optimized, and either hire

RNs into enhanced roles or reconﬁgure the roles of those already on the

team. The RN roles should include care management and coordination

for aging and chronically ill patients and those with increasingly complex

health needs; promoting health and improving patients’ self-management

of prevention and behavioral health issues; and placing greater emphasis

on transitional care, prevention, and wellness. Practices should optimize

2 Examples of exemplary primary care practices are included in this monograph.

the potential of RNs, allowing them to spend ample face-to-face time with

patients.

2. Health systems and primary care practices should support the

transformation from practitioner-dominated care models to team-based

care models (“I to we”), with RNs leading the primary care team when

appropriate given their expertise.

3. Payers should develop alternative payment models—such as shared savings

for reducing expensive hospital admissions, re-admissions, and emergency

department visits—so that the work of all primary care team members,

including RNs, adds value rather than simply increases expenses. In fee-

for-service systems, speciﬁc RN-visit types, such as Medicare wellness visits

and care coordination, should be reimbursed at a higher level. RNs should

be encouraged to acquire a National Practitioner Identiﬁer (through the

National Plan and Provider Enumeration System) for both payment and

tracking purposes.

4. Nursing, primary care, and health services researchers as well as primary

care administrators and chief ﬁnancial ofﬁcers should develop the business

case for enhanced RN roles in primary care, with an emphasis on their

impact on quality; costs; patient, family, and team member and staff

satisfaction; and their contributions to addressing social determinants of

health in primary care settings. The evidence-based Ambulatory Nurse-

Sensitive Indicators provides a much-needed tool to assist in quantifying

the value of RNs in primary care.

5. Healthcare systems, professional organizations, states, and other regulatory

entities should identify barriers, real and perceived, that limit or impede

enhanced roles in primary care for registered nurses. Of particular

importance are strategies for reducing barriers presented by outdated state

practice acts that may limit RNs’ abilities to utilize their skills to the fullest

extent. State medical and nursing boards and health system leaders should

rely on research that supports enhanced roles in primary care for RNs,

and they should facilitate the adoption of evidence-based guidelines and

standing orders that empower RNs to carry out these roles.

RECOMMENDATION III

Educating Nursing Students in Primary Care. Nursing school leaders and faculty

should elevate primary care content in the education of pre-licensure and RN-to-

BSN nursing students.

A multi-pronged approach that spans classroom and clinical instruction is critical

to elevating primary care in nursing education. Interventions include developing

the pipeline of students interested in primary care, re-balancing curricula between

acute and primary care instruction, and supporting graduates in seeking RN roles

in primary care. The re-balancing of curricula to incorporate primary care content

should be informed by adult learning theory and educational scholarship. These

efforts will create a movement to build a critical mass of RNs in primary care.

Actionable Recommendations

1. Nursing schools should work with the communities they serve to develop

a pipeline of diverse students to meet the needs of diverse patient

populations. Admissions criteria should be broadened to identify

candidates with particular interest in and aptitude for primary care and

community service.

2. Nursing faculty must broaden and deepen the primary care focus in

the curriculum. Doing so includes enriching content on topics such as

wellness, health promotion, and disease prevention; population health and

risk stratiﬁcation; motivational interviewing and health coaching; health

equity; leadership, cost of care, delivery models and systems innovations;

care coordination and care transitions; chronic care and complex care

management with associated behavioral health concerns; longitudinal

care throughout the lifespan; culture change and primary care practice

transformation; informatics and data analytics; and telehealth and virtual

delivery models.

3. Schools of nursing must reach out to primary care practices to develop

innovative arrangements for meaningful clinical experiences for nursing

students. Accomplishing this will require that schools create an inventory

of primary care practices, partner with them to develop enhanced clinical

experiences that can include longitudinal opportunities for students

to serve the same individual and family across settings, and adapt the

designated education unit concept in high-performing primary care sites.

4. Nursing faculty must provide opportunities for students to have exposure

to primary care outside of the curricular experiences. This exposure could

include informing students of the opportunities to delve more deeply into

issues in primary care through working with organizations that promote

primary care, such as Primary Care Progress.

5. Nursing faculty should establish a strong evaluation and research

component to improve on curricular changes and identify best practices

in preparing pre-licensure and RN-to-BSN students for enhanced roles

in primary care. This component could include examining the impact of

curricular changes on licensure performance and career choices.

RECOMMENDATION IV

Supporting the Primary Care Career Development of RNs. Leaders of primary

care practices and health systems should facilitate lifelong education and

professional development opportunities in primary care and support practicing RNs

in pursuing careers in primary care.

Registered nurses working in primary care practices or interested in transitioning

into primary care will need to strengthen or build primary care knowledge and

competencies in areas that include chronic disease management, care coordination,

care transitions, prevention and wellness, interprofessional teamwork, and triaging.

This skills acquisition will require a learning system designed to assure that the

most recent knowledge for innovation, evidence, system design, leadership, and

technology within primary care settings is available and accessible to practicing

RNs. Educational modalities should be varied, ﬂexible, and promote development

of a diverse primary care RN workforce, including opportunities for academic-

practice partnerships, residency programs, and engagement in the redesign of

primary care practice.

Actionable Recommendations

1. Schools of nursing, health systems, and professional organizations should

create opportunities for lifelong education and professional development

in primary care for RNs, including nurse managers and executives. Potential

partners who can help develop learning modules include professional

nurses associations as well as national organizations focused on healthcare

transformation.

2. The American Nurses Credentialing Center (ANCC) should establish

a Magnet®-type recognition program for primary care practices, or

incorporate a primary care focus into the existing Magnet® program. This

would encourage primary care systems to create practice environments

known for their excellence in nursing practice and high-quality care. The

ANCC should convene leaders within professional nursing associations to

develop an action plan.

3. Academic and practice leaders should develop academic-practice

partnerships across primary care settings and schools of nursing to create

residency programs in primary care; enhance RN development; co-

design curricula and toolkits for implementing educational programs; and

disseminate co-designed curricula to organizations supporting primary care

transformation, such as health plans, foundations, and consultant agencies,

as well as entities that provide continuing nursing education.

4. Primary care practices should establish opportunities to engage registered

nurses in the redesign of primary care with foci on full RN practice

authority, leadership, and interprofessional practice.

5. Primary care practices and organizations involved in training healthcare

professionals should provide staff development and continuing education

on enhanced RN roles at the practice level, prioritizing RN-led contributions

to the speciﬁc needs of the community served by the practice and

reﬂecting the culture, language, and values of the community.

RECOMMENDATION V

Developing Primary Care Expertise in Nursing School Faculty. Academia and

healthcare organizations should partner to support and prepare nursing faculty to

educate pre-licensure and RN-to-BSN students in primary care knowledge, skills,

and perspective.

Although some nursing faculty teach primary care content in undergraduate

programs, many are more comfortable teaching acute, inpatient hospital content in

classrooms and clinical settings. To re-balance nursing education toward a greater

primary care orientation, there is a need for considerable faculty development in

the areas of primary care nursing knowledge, skills, and functions. Academia and

ambulatory practices should work together in this endeavor.

A primary care perspective not only looks at an acute inpatient episode in a

patient’s life, but also concerns itself with the entire trajectory of a patient’s illness

throughout the lifespan. Moreover, while nursing care in acute settings has focused

on RNs implementing the orders of practitioners (physicians, nurse practitioners,

or physician assistants), RNs in ambulatory practice may make autonomous patient

care decisions within their scope of practice and under standardized protocols.

Actionable Recommendations

1. Deans, other leaders of nursing education, and faculty should utilize an

interprofessional model of RN faculty development. Faculty who achieve

competence in primary care practice should be recognized and rewarded

for their broadened knowledge, expertise, and skills.

2. Health systems and health insurers should help fund faculty development,

including residencies and fellowships in primary care nursing, as they

may beneﬁt ﬁnancially from the enhanced RN primary care roles. Further,

schools of nursing should develop innovative partnerships with primary care

practices to help them recruit faculty and develop instructional materials

and other educational resources on the primary care nursing paradigm.

3. Nurses actively working as care coordinators, chronic care managers,

and other enhanced roles in primary care should have joint faculty

appointments to teach both didactic and clinical primary care

competencies. Nursing faculty should spend time working in primary care

practices to enhance their own skills and close the gap between education

and practice.

4. Nursing faculty should model an RN culture of equal partnership with

physicians and other team members, such that RNs become comfortable

caring for patients autonomously under standardized protocols as

authorized by state nursing boards. Faculty should educate nurses to care

for patients not only during an acute episode of illness but also throughout

their lifespan and across acute care, primary care, and home settings,

paying attention to socioeconomic, cultural, and environmental factors

impacting the health of the population.

5. Partnerships should be developed between nursing schools, other health

professions schools, and health systems to further the integration of

RN education and interprofessional education with primary care clinical

practice. Partnerships may be contractual, specifying the responsibilities

of each party, or involve a health system partnering with a nursing school

to create the strongest possible integration between RN education and

practice.

RECOMMENDATION VI

Increasing Opportunities for Interprofessional Education. Leaders and

faculty in nursing education and continuing education programs should include

interprofessional education and teamwork in primary care nursing curricula.

Interprofessional teams are key to successfully transforming primary care to meet

the healthcare needs of the public. Thus, opportunities for interprofessional

education (IPE) and teamwork are essential in the preparation and continuing

education of all primary care team members, including registered nurses.

This theme cuts across all prior recommendations on education and faculty

development, but conferees felt it was of such paramount importance that it should

be reinforced as a separate recommendation.

Actionable Recommendations

1. All primary care nursing education curricula should incorporate core

interprofessional competencies, such as those developed and disseminated

by the Interprofessional Education Collaborative and the Quality and

Safety Education for Nurses Institute. Additional foundational support

for IPE curriculum development is available from the National Center

for Interprofessional Practice and Education and from the Institute for

Healthcare Improvement’s Open School. Essential steps include:

• Convene leading health professions education and practice

groups, and patient and family representatives, to co-develop the

curriculum;

• Identify competencies to prepare registered nurses for expanded

roles in primary care; and

• Ensure that the curriculum is deployed in the continuum of education

of current and emerging primary care professionals. One example

of an educational tool that includes interprofessional elements is the

American Academy for Ambulatory Care Nursing’s modules for clinical

care coordination and transition management.

2. Deans and faculty should position students from all professions to bridge and

accelerate the connection of academia and practice and to drive change in

practice sites. For example, have students from multiple professions work with

a shared panel of high-risk primary care patients or engage in a classroom

discussion about best practices in primary care.

3. Deans and faculty should leverage technology as a catalyst to spread

innovative curricula and collaborative practice in primary care. Technology

fosters better education and collaboration in primary care teamwork. For

example, simulations may be used to model important resource management

challenges. One scenario, for example, might require all team members

to use the same electronic health record screens to record and integrate

information about a patient.

CONCLUSION

Preparing registered nurses for enhanced roles in primary care is an urgent issue;

exemplary practices show that these enhanced roles are achievable.

Tosucceed in this endeavor, primary care and nursing education need to

undergo fundamental culture change, assisted by the engagement, support,

and commitmentof a wide variety of stakeholders. Patients will be the ultimate

beneﬁciaries.

West County Health Centers, Inc. in California

JASON CUNNINGHAM

In California’s Sonoma County, West County Health Centers, Inc., has moved

strategically toward a care delivery model that focuses on relational, continuous,

accessible, team-based care. In particular, West County has invested in the role

of registered nurse (RN) care manager as a critical member of the primary care

team. The approach provides both diagnosis and treatment across the spectrum

of disease acuity and offers proactive preventive care, self-management support,

care coordination, chronic disease case management, and focused behavioral

modiﬁcation support for complex outliers.

It is clear that patients require different levels of investment as they move through

different life stages and health challenges and will need to be empowered to

engage more fully in health solutions. Additionally, as patients develop more

complex health needs, they require a more comprehensive, system-wide

approach that maximizes traditional healthcare delivery and provides additional

case management and care coordination. A smaller number of patients who

utilize a disproportionate amount of resources in the current healthcare delivery

system require a different approach to care delivery that focuses on behavioral

interventions to change their clinical outcomes and move them toward more

appropriate healthcare utilization.

PRIMARY CARE

EXEMPLARS

Transformed Care Delivery Model

At the heart of West County Health Centers’ care delivery model are two core

principles: (1) the main product in primary care is the relationship with the patient

and (2) effective primary care can only occur in the context of a highly effective and

empowered team. As William Osler said, “It is more important to know what sort of

patient has a disease than what sort of disease a patient has.” All of health care is

“relational,” but within primary care, “trusting, long-term, healing relationships” are

at the core of the product.

Understanding a patient’s particular needs, interests, and approach to health within

the context of his or her community allows a primary care team to move beyond the

urgent need and become and effective enabler of health at all stages of a patient’s

life journey. The deep healing relationship with the patient is more effective if it

is born out of many touches with the patient over a period of time, and where

applicable, in the patient’s home environment. This becomes increasingly important

as primary care moves into caring for patients with multiple chronic illnesses,

complex mental health needs, co-morbid addiction, and underlying history of

trauma, and as it moves toward understanding and reducing inappropriate health

system utilization and cost.

West County Health Centers, Inc., serves a socially and medically complex

population in rural western Sonoma County in northern California. Between the four

primary care clinic sites, the federally qualiﬁed health center cares for approximately

14,000 unique patients, 80% of whom are below 200% of the federal poverty level.

The primary “care team” consists of a medical provider, an RN care manager, a

medical assistant, and front ofﬁce staff.

The team is empowered to care for a panel of patients throughout the continuum of

patient care, including prenatal, obstetrical, preventive, and geriatric services. The

team is accountable for clinical outcomes and each member of the team interacts

and is incentivized based on role-speciﬁc population health data at a patient

and aggregated level. The primary care teams are supported by an integrated

behavioral health team that includes staff specialized in addiction services and

community health resources. The ratios for one full-time equivalent (FTE) primary

care provider are as follows: 1.75 medical assistant, 1.75 front ofﬁce staff person, 1.2

RN care manager, 1.0 behavioral health staff member, and 0.3 community health

worker. Each FTE panel cares for approximately 1,200 risk-adjusted patients.

The RN Care Manager Role

RN care managers are at the core of supporting patients with complex health needs

or high-risk clinical events. While RN care managers provide traditional clinical

triage and assist medical providers and the rest of the care team with patient tasks

during ofﬁce visits, West County has prioritized the unique skills and background

of RN care managers to focus on care provided between ofﬁce visits. This includes

care coordination with other health systems, chronic disease care management for

patients who are not meeting speciﬁc health targets, hospital and ER transitional

care, high-risk disease and lab tracking, and care management for higher cost/

higher utilization patients. RN care managers also coordinate services with other

members of the care team, behavioral health staff, and community health workers

for speciﬁc patient needs and provide an invaluable role in communication and

coordination with patients.

West County Health Centers’ stafﬁng model is fully funded within the operating

budget of the agency and does not rely on increased productivity or increased

charge capture to remain solvent. Financial viability is achieved by a strong

commitment from agency leadership to the current care delivery model, with

very lean operational costs and overhead. West County has realized increasing

ﬁnancial reimbursement from its managed Medicaid health plan, fee-for-service

reimbursement for hospital transition care, and an “Intensive Outpatient Care

Management” grant for reducing costs and utilization for high-risk patients.

Further, West County Health Centers, Inc., receives reimbursement for chronic

care management from the Centers for Medicare & Medicaid Services and has

partnered with four other community health centers to start an accountable

care organization.

West County Health Centers has been on its current journey of care delivery

transformation for the past 10 years. It recognized early that primary care redesign

is complex, takes a signiﬁcant amount of time, and requires a commitment

to comprehensive team transformation. The role of the RN care manager has

been the most complex in the redesign process, requiring high-functioning

medical assistants as well as behavioral health and front ofﬁce staff members

to support work that would commonly compete for the time and priority of the

RN. It also requires a strong commitment by agency leadership to focus on care

that is not reimbursed in the traditional primary care environment. West County

has committed to developing and stafﬁng the role of the RN care manager,

understanding that RNs will continue to play a critical role in a transformed

primary care environment.

Community Health Center, Inc. in Connecticut

MARGARET FLINTER

Since its establishment in 1972, Community Health Center, Inc., (CHC) has grown

from a free storefront clinic in downtown Middletown, Connecticut, into one of the

nation’s largest community health centers, providing comprehensive care to more

than 145,000 patients through a statewide network of 14 primary care sites and

more than 200 service delivery locations.

Innovative, Team-Based Care

As a patient-centered medical home, CHC provides fully integrated, team-based

care. CHC’s primary care providers (physicians, nurse practitioners, and physician

assistants) are supported by highly trained registered nurses (RNs); medical

assistants; behavioral health therapists; and extended care team members,

including chiropractors, psychiatrists, registered dieticians, and others. Each team

member contributes their unique role and skills, all practicing at the top of their

license, training, or certiﬁcation.

To ensure care is of the highest quality, CHC established the Weitzman Institute, a

research organization with a staff skilled in quality improvement tools, sophisticated

data management, and health information technology to develop and implement

evidence-based solutions to improve primary care delivery.

To support advanced training for its providers, CHC developed its own Weitzman

Institute Project ECHO® videoconference education program, based on the

successful pilot by the University of New Mexico Health Sciences Center. Today,

more than 600 participants from 91 organizations in 23 states have joined Weitzman

Project ECHO clinics for training and support in management of chronic pain,

hepatitis C, HIV, substance abuse, pediatric and adolescent behavioral health,

LGBT health, and quality improvement. This model was then translated to support

our registered nurses in developing the capacity to implement complex care

management.

CHC and the Weitzman Institute also developed eConsults, a secure messaging

system for consultations, reducing patient wait times from as much as a year to

just a few days. eConsults now conducts teleconsults in cardiology, dermatology,

endocrinology, gastroenterology, neurology, ophthalmology, orthopedics, and pain

management. CHC recently incorporated the Community eConsult Network to

provide rapid consultations to primary care providers throughout the country.

Training the Next Generation

CHC has a deep commitment to training the next generation. To address the

need for intensive preparation for practice careers as primary care providers in the

safety net setting, CHC developed a model of postgraduate nurse practitioner

(NP) training, and established the nation’s ﬁrst NP residency program in 2007. CHC

also sponsors a postdoctoral clinical psychology residency and provides technical

assistance to health centers across the country through its National Cooperative

Agreement on Clinical Workforce Development. In 2016, CHC established the

National Institute for Medical Assistant Advancement to ensure this vital role on the

team also has the beneﬁt of superior training that incorporates advanced skills not

covered in traditional programs.

Participating in the Precision Medicine Initiative

CHC continues working to improve care with its selection as part of the National

Institutes of Health Precision Medicine Initiative Cohort program, which aims to

engage at least one million people in research to improve the prevention and

treatment of disease based on individual differences in lifestyle, environment,

and genetics. CHC’s diverse patient population will provide a wealth of vital

health information to this ambitious national project that will shape the future of

healthcare delivery.

The Role of the Registered Nurse

CHC is dedicated to developing and advancing the role of the registered nurse in

primary care, and as a critical member of the care team. Along with a primary care

provider, every CHC patient has an RN on their team who is able to support the

patient through virtual and ofﬁce visits; actively manage chronic illness through

standing orders and protocols; and assess and treat those health concerns that

can be medically managed under standing orders but beneﬁt from the added

education, counseling, and support of RNs. RNs function as coaches, advocates,

coordinators, and complex care managers as they approach population health

by proactively co-managing patients with primary care and behavioral health

providers, particularly those patients with multiple or poorly controlled chronic

illness and complicating social determinants of health.

RNs at CHC have access to a variety of tools to support their work, including an

RN-led Project ECHO focused on complex care management, clinical decision

support in the form of data dashboards, and a personal clinical scorecard that

enhances their ability to track the impact of their work on patient health outcomes

over time. CHC is also accredited as a provider of continuing nursing education by

the American Nurses Credentialing Center’s Commission on Accreditation.

CHC’s RNs are dedicated to training the next generation of nurses with the

implementation, in January 2016, of a primary care-focused dedicated education

unit. This innovative model ensures that senior-year nursing students in bachelor’s

programs acquire a ﬁrm understanding of the full continuum of care that patients

travel through, along with a better grasp of what an integrated team-based model

of care that emphasizes the critical role of RNs really looks like. Regardless of where

these students work as nurses after graduation, they will be able to support more

effective transitions of care, have an enhanced understanding of the various roles

of nurses across the continuum, and may be more likely to choose primary care as

their ﬁnal career.

Clinica Family Health in Colorado

MALIA DAVIS

Clinica Family Health is a federally qualiﬁed health center (FQHC) that is a crucial

piece of the medical safety net for low-income and uninsured residents in the

southern Boulder and northwestern Denver metropolitan areas of Colorado.From

its founding, in 1977, as a single nurse practitioner facility with 500 patients, Clinica

has grown into a multi-site organization that provides comprehensive primary and

preventive healthcare services to more than 47,000 people annually.

Clinica is the only organization in its service area that delivers a full spectrum of

integrated medical, dental, and behavioral health care on a reduced-fee, income-

based sliding scale basis to patients of all ages.It currently has ﬁve medical and two

dental clinics that provide approximately 200,000 appointments annually, and 93%

of its patients have incomes below 200% of the federal poverty guidelines and 29%

are completely uninsured.More than 80% of Clinica’s patients are from a minority

group and it provides a medical home to more than 30,000 Latino patients each

year.All direct medical care personnel are English/Spanish bilingual.

Innovative Methods

Clinica’s innovative methods have drawn the attention of several major media

outlets. The New England Journal of Medicine devoted a story to Clinica’s “high-

functioning” care delivery system in July 2011. PBS’ Newshour aired a story about

Clinica’s advanced diabetes care model and Health Affairs featured Clinica in its

“Innovations” series. The National Committee for Quality Assurance (NCQA) has

awarded Clinica the highest level of Patient-Centered Medical Home (PCMH)

certiﬁcation as well as Diabetes Recognition Program certiﬁcation for all its service

delivery sites. Clinica also received Ambulatory Health Care Accreditation from the

Joint Commission. In spite of its advanced service model, Clinica spends less per

visit on average than other community health centers. In 2015, Clinica’s average

cost per visit was $188.58, compared with the $222.61 average statewide. The

national average was $207.21 per visit.

RNs in Primary Care

Recently, Clinica has continued to foster innovation with changes to its care delivery

model, speciﬁcally through the development of the primary care RN role. Clinica’s

nurses lead its complex care management work and participate in co-visits, which

are patient visits shared between an RN and a medical provider. Using RNs on

co-visits has helped Clinica improve patient access to same day care by making

more appointments available every day and by reducing double booking while

adding total visits. Co-visits also provide for more time for patient education and

discharge instructions and decrease telephone triage and tasking. Clinica also

has seen improved care team communication and team work, as well as improved

patient and care team satisfaction. An article about Clinica’s co-visit model titled,

“Enhancing the Role of the Nurse in Primary Care: The RN Co-Visit Model” was

published in the Journal of General Internal Medicine in 2015.

Medical Associates Clinic in Iowa

THOMAS SINSKY

Thirty years ago, when Dr. Tom Sinsky ﬁrst started his practice at Medical

Associates Clinic in Dubuque, IA, his practice partner was a registered nurse (RN).

Over the years, as the complexity and intensity of outpatient care have accelerated,

the clinic’s team model has evolved. Its current core team consists of one physician

and three RNs working closely together to provide continuous complex care to a

panel of patients. The larger “pod team” also includes another physician working

with three RNs and a nurse practitioner teamed with one RN.

What do Patient Visits Look Like?

Depending on the nature of the appointment, the patient will spend the ﬁrst 5–20

minutes with one of the three registered nurses. Prior to the appointment, an RN

will review all lab results and will then discuss them with the patient during the visit.

This is a time when the nurse will use her medical knowledge and teaching skills to

help the patient engage more fully in his or her own care as the patient reviews the

meaning of test results, such as HbA1c or cholesterol levels.

The RN also will gather information about the patient’s other health issues. For

instance, at the time of the annual Medicare wellness appointment, she will

assess the patient’s risk for falls, screen for depression, and provide information

on advance directives. The registered nurse also will update the patient’s

immunizations as needed, and will discuss and schedule screenings, such as

colonoscopies, bone density scans, and mammograms. For patients who are

diabetic, the nurse will perform and document the diabetic foot exam and schedule

the annual diabetic eye exam. In short, RNs attend to prevention-related tasks as

well as management of the patient’s chronic conditions before the physician enters

the exam room.

Registered nurses also initiate discussions to explore any current family issues or

social stressors in that patient’s life. She might learn, for example, that the patient

is dealing with the recent death of a family member or loss of a job. Or perhaps

they might be excited by the arrival of a new grandchild or have just returned

from vacation. This is important information because it helps us to get to know

our patients as unique human beings and establish strong, trusting, long-term

relationships with them.

For acute problems, the RN obtains the initial history of symptoms, and she also

has standing orders for symptom-driven tests. So if the patient has chest pain or

shortness of breath, using her own judgement, the RN might obtain an EKG or

perform pulmonary function tests and obtain an oxygen saturation level.

For all visits, the RN performs the important task of medication reconciliation and

also obtains weight, blood pressure, and pulse. This not only provides important

information, but provides an opportunity for the nurse to touch the patient. That

simple act of physical contact helps nurture a caring, trusting relationship. When

she has completed all this work, the nurse checks in with the physician and they

both return to the exam room to join the patient.

The nurse then provides an oral presentation of the patient’s concerns, symptoms,

vital signs, lab results, and social issues to both physician and patient, allowing

the patient the opportunity to listen and elaborate or clarify if necessary. This

approach becomes a three-way discussion between the patient, RN, and physician.

The physician then performs a physical exam and makes necessary medical

decisions and formulates a plan, which the RN enters into the electronic health

record in real time.

The physician moves on to another patient, while the RN stays in the room and

performs the crucial work of operationalizing the therapeutic plan. She answers

any further questions that the patient might have, provides teaching and health

coaching as needed, sends off prescriptions, and then escorts the patient to the

receptionist for scheduling of future appointments. If the patient calls back later

with questions, the RN is able to answer them because she was with the patient

throughout the entire visit.

On any given day, when 30–35 patients may be seen in clinic, another 100 patient

encounters may occur via phone calls, emails, and faxes. This volume of work

requires a ﬁnely tuned, well-organized team. Almost all of this important complex

personalized work between visits is performed by RNs. Whether performing face-to

face-work during a clinic visit or phone, fax, or email work between visits, the RN is

engaged in work grounded in long-term, trusting, healing relationships and working

at the top of their license using all of their medical, managerial, and communication

skills in caring for patients.

Commissioned Paper

THOMAS BODENHEIMER, MD, MPH

UCSF Center for Excellence in Primary Care

and

LAURIE BAUER, RN, MSPH

and UCSF School of Nursing

Commissioned Paper

THOMAS BODENHEIMER, MD, MPH

UCSF Center for Excellence in Primary Care

and

LAURIE BAUER, RN, MSPH

and UCSF School of Nursing

THE FUTURE OF

PRIMARY CARE

ENHANCING THE REGISTERED NURSE ROLE

INTRODUCTION

A vibrant national movement is sweeping primary care, spawning high-performing,

patient-centered practices. The numbers of nurse practitioners and physician

assistants are growing, adding to the primary care practitioner workforce.

Discussions are intensifying on payment reform, supporting the evolution from a

physician-does-everything model to team-based care.

The challenges are formidable. Society expects primary care practices to provide

accessible and comprehensive care to the American population; yet, primary

care is underpaid, receiving only 5% of the total healthcare dollar.

Panel sizes are

large, making it difﬁcult for practitioners to spend sufﬁcient time with patients.

In addition to providing 20–25 daily patient encounters to an increasingly elderly

population, primary care practitioners are supposed to track and improve upon

a potpourri of performance measures. With these increasing demands and

insufﬁcient resources to meet them, primary care practitioner burnout is a serious

and persistent problem.

This paper explores the hopes and fears of primary care in the 21

century and

examines the likelihood of expanded roles for registered nurses in primary care.

WHY PRIMARY CARE MATTERS

A large body of research demonstrates that more primary care is associated with

improved outcomes and reduced healthcare costs.

In a state-by-state analysis

of 24 quality-of-care measures, states with more primary care physicians had

higher quality and lower Medicare costs, while states with fewer primary care and

more specialist physicians had lower quality and higher Medicare costs.

Similar

communities with an adequate supply of primary care have lower infant mortality

and all-cause mortality, fewer hospital admissions, and reduced healthcare costs

compared with those lacking sufﬁcient primary care.

PATIENTS’ VIEWS OF PRIMARY CARE

Studies addressing what patients want from physicians suggest four things: I want

my physician to know how to help me (competence); I want my physician to care

about me (empathy); I want my physician to know me as a person (familiarity); and I

want to see my personal physician when I need care (continuity).

7,8

Public opinion polls show that many patients do not universally experience these

traits from their physicians. In 2012, 44% of patients were not satisﬁed with the

treatment received during their last doctor visit.

In 2008, only 56% of US adults

ages 19–64 reported having a primary care practitioner who was easy to access in

a timely fashion.

In a study of 264 audiotaped visits to family physicians, patients

making an initial statement of their problem were interrupted after an average of 23

seconds.

It is likely that these problems are related to primary care practitioners’ large panel

sizes and brevity of visits. A 2005 analysis of adult primary care visits found that

the average visit time was 20.9 minutes, while the average number of clinical items

addressed per visit rose from 5.4 in 1997 to 7.1 in 2005.

Research also found that

44% of primary care physicians are dissatisﬁed with the amount of time they are

able to spend with patients.

And, while nurse practitioners spend more time with

patients, with greater patient satisfaction, they are being exhorted to provide more

and faster visits.

THE CENTRAL ROLE OF CHRONIC DISEASE IN

PRIMARY CARE

Currently, 75% of primary care visits are for chronic illnesses.

In 2012, 50% of

US adults had at least one chronic condition, and 12% had three or more chronic

conditions. Between 1980 and 2015, the US population 65 and older grew from

25.5 million to 47.8 million, and will add almost two million people yearly, reaching

74.1 million in 2030. Among elderly adults, 86% have at least one chronic condition

and 33% have three or more chronic conditions.

16,17

Over one-third of US adults

are obese and over two-thirds are overweight. Without serious prevention efforts,

the US prevalence of diabetes will grow from 41 to 61 million between 2015 and

2030.

These realities underlie the widespread adoption of the chronic care model,

which teaches that teams are essential to chronic disease management,

and that

registered nurses (RNs) in particular have a major role to play as chronic disease

care managers.

TRENDS IN PRIMARY CARE PRACTICE

Historically, primary care was practiced by family physicians, general internists,

and general pediatricians. During the last decades of the 20

century, the new

professions of nurse practitioner (NP) and physician assistant (PA) appeared, and

from 1999 to 2009, the number of physician ofﬁces with at least one NP, PA, or

certiﬁed nurse midwife increased from 25% to nearly 50%.

Primary care provides

55% of ambulatory care visits nationwide, but only 32% of physicians practice

primary care.

In this paper, the phrase “primary care practitioner (PCP)” refers to physicians,

nurse practitioners (NPs), and physician assistants (PAs)—those who are authorized

to diagnose and treat and who currently can bill for their services. The broader term

“clinician” includes PCPs and other professional team members, such as registered

nurses, pharmacists, and behaviorists.

Over the past decade, practice size has undergone a major change. The

percentage of physicians in solo practice declined from 41% in 1983 to 18% in

2014,

and primary care is experiencing similar trends. A high proportion of solo

physicians are older, suggesting that solo practice may eventually disappear

entirely. The percentage of physicians in practices of 50 physicians or more grew

from 3% in 2001 to 36% in 2011, with similar trends for primary care. Many primary

care physicians are also in mid-sized practices of 6–50 physicians.

23,24

Practice ownership has also experienced rapid change. From 2002 to 2008, the

percentage of practices owned by physicians dropped from 70% to 50% while the

percentage owned by hospitals increased from 20% to 50%. This trend continues

in 2015 and is more pronounced for primary care than for specialty practices.

25,26

Three-fourths of physicians leaving residency begin their careers as employees

of a hospital or medical group. Another practice ownership model is the nurse-

managed health clinic (NMHC), led by an NP or other advanced practice nurse. In

2014, about 250 NMHCs were in operation; they are expected to provide 5% of US

primary care in 2025.

27,28

The pillars of primary care are ﬁrst contact care (access), continuity of care,

comprehensive care, and care coordination.

In the past, primary care physicians

cared for their patients in both ambulatory and in-patient settings and regularly

interacted with specialists in the hospital, allowing easy coordination of care

between ofﬁce and hospital. Patients generally enjoyed continuity of care and

access to their personal physician because physicians worked full time.

Today, the primary care pillars are facing major challenges because of the trend

toward part-time practitioners and the hospitalist movement, which grew rapidly

after the 1990s, fracturing the natural familiarity between primary care physicians

and specialists.

NPs and PAs, whose patients have healthcare outcomes

equivalent to those of physicians, have played an essential role in improving both

access and continuity, and some practices have hired RN care coordinators to assist

patients in coordinating care within the medical neighborhood surrounding the

primary care home.

With the 21

century has come a ﬂurry of even more changes in primary care

practice. Today, primary care is expected to take responsibility not only for the

care of individuals, but also for the health of its population of patients, requiring

practices to empanel their patients and create registries to track quality measures.

The federal government provided ﬁnancial incentives to adopt electronic medical

records (EMRs), which has pushed more work onto practitioners and added time-

consuming documentation demands.

In 2015, only 52% of US physicians were satisﬁed with their EMR in compared with

86% in the UK, 77% in Germany, and 76% in the Netherlands.

Primary care came

under the scrutiny of government and private payers and the provider systems

of which they were part, measuring performance in the areas of clinical quality,

patient experience, and practice operations. Panel size for the typical primary care

physician averaged over 2,000 patients, creating an almost impossible task; for one

practitioner to provide excellent preventive and chronic care would take 16 hours

per day for a panel that size.

With practitioners unable to provide the totality of

services mandated to primary care, RNs are being asked to take on the population

health and chronic care responsibilities of primary care.

PRIMARY CARE PRACTITIONER WORKFORCE TRENDS

Projections for PCP workforce shortages vary widely, though all analysts agree that

1) there is a growing gap between the population’s demand for primary care and

the number of primary care physicians available to meet that demand, and 2) NPs

and PAs will narrow but not close that gap.

A simple way to think about supply projections is to start with the existing

supply, estimate the number of new practitioners (physicians, NPs, PAs) per year,

the number of practitioner retirements per year, and the number of full-time

practitioners transitioning to part time per year. Projections vary widely because

these estimates are difﬁcult to make.

On the demand side, the population’s demand for primary care is increasing

because of population growth, the rapid growth of the elderly demographic, more

insured people under the Affordable Care Act (ACA), and the diabetes and obesity

epidemic.

31,32

Physicians

In 2010, there were 210,000 primary care physicians (family doctors, general

internists, and general pediatricians) practicing in the US.

The number of primary

care physicians per population increased only 14% from 1980 to 2012 while the

total number of physicians increased 73%. About 8,000 primary care physicians

(including doctors of osteopathy and international medical graduates) entered the

workforce in 2015, only slightly up from 7,500 in 2005. Without an unlikely spike in

medical and osteopathic students entering primary care practice, the number of

entrants is expected to plateau around 8,000.

33,34

The number of primary care physician retirements was about 6,000 in 2015 and is

projected to increase to 8,500 in 2020.

Thus, in 2020, the number of retirements

may equal or exceed the number of new entrants, which would cause the primary

care physician workforce to decline in relation to a growing population.

The number of hours worked by primary care physicians has been dropping. In

2014, the average family physician worked 47 hours per week, down from 51 in

1998.

35,36

Women physicians work about seven fewer hours per week than men, and

by 2025, half of the primary care physician workforce will be women.

Based on projections of supply and demand, several organizations have estimated

the future shortage of primary care physicians. The federal Bureau of Primary

Health Care estimates a primary care physician shortage of 20,400 by 2020.

The

Association of American Medical College’s shortage estimates range from 12,500

to 31,100 by 2025.

The American Academy of Family Physician’s Robert Graham

Center predicts a shortage of 17,000 in 2025.

Nurse practitioners

In 2012, an estimated 127,000 NPs were actively providing patient care in the US.

Estimates of the proportion working in primary care vary, but it is probably about

50%.

38,39

Data from 2010 estimate the number of primary care NPs at 56,000.

The number of nurse practitioners entering the workforce each year has increased

rapidly from 6,600 in 2003 to 18,000 in 2014, giving the profession the distinction

of being the fastest growing within primary care.

The number of primary care NPs

is projected to reach 103,000 by 2025.

Physician assistants

In 2013, 93,000 certiﬁed physician assistants (PA-Cs) were in active practice with

32% working in primary care an average of 39 hours per week.

The number of

yearly PA-C entrants grew from 4,000 in 2002 to 7,500 in 2014, and is projected to

reach 8,000 by 2020.

The number of primary care PAs is estimated to increase

from 30,000 in 2010 to 42,000 in 2025.

Total primary care practitioners

The primary care physician, NP, and PA workforce trends portend a striking change

in the composition of primary care practitioners. In 2010, there were about 210,000

primary care physicians, 56,000 primary care NPs, and 30,000 primary care PAs:

a total of 296,000 primary care practitioners. In 2025, there will be an estimated

216,000 primary care physicians, 103,000 primary care NPs, and 42,000 primary

care PAs: a total of 361,000. In 2010, physicians made up 71% of PCPs; in 2025, that

percentage will drop to 60% while NPs as a percent of the PCP workforce will jump

from 19% to 29%. In 2010, there was one primary care NP for every four primary

care physicians; in 2025, there will be about one NP for every two physicians.

Primary care practitioner (PCP) workforce trends

Number in

2010

% of total

PCPs, 2010

Number in

2025

% of total

PCPs, 2025

Physicians 210,000 71% 216,000 60%

NPs 56,000 19% 103,000 29%

PAs 30,000 10% 42,000 11%

Total 296,000 100% 361,000 100%

Will the primary care practitioner shortage continue? Even with many new NPs

and PAs, the primary care practitioner to population ratio will fall by 8% from

2010 to 2025. In addition, the demand for primary care is growing faster than the

population because of several factors, including the aging of the population, an

increase in chronic disease, an epidemic of diabetes and obesity, and the expansion

of health insurance coverage. The US National Center for Health Workforce Analysis

estimates a shortage by 2020 of 20,400 primary care physicians, but only 6,400

primary care practitioners.

At least three other factors will impact the shortage projection. First, primary

care physicians are reducing their work hours.

35,36

Second, 47% of primary care

physicians, compared with 27% of NPs and PAs, report that they are considering

early retirement.

Third, the capacity for NPs to provide care equivalent to that

provided by physicians depends on NPs being granted full practice authority. In

2015, 21 states and the District of Columbia had granted NPs full practice authority;

the other states had varying degrees of restrictions.

In summary, there continues to be a demand-supply gap for primary care, but the

growth in the primary care nurse practitioner and physician assistant workforce

substantially ameliorates that gap. Currently, some primary care NPs are performing

the roles of chronic care managers and care coordinators. In the future, however,

primary care NPs will be increasingly indistinguishable from physicians, meaning

that RNs will be needed to assume the growing chronic care management and care

coordination responsibilities.

PRIMARY CARE FOR UNDERSERVED POPULATIONS

Many rural counties and low-income urban neighborhoods have been designated

as Primary Care Health Professional Shortage Areas, with less than one primary care

physician for every 3,500 people. Rural areas have 68 per 100,000, compared with

urban areas, which have 84 per 100,000.

Among the 62 million Americans living in

primary care shortage areas, 43% are low income, 28% live in rural areas, and 38%

are racial/ethnic minorities.

Primary care NPs are more likely than primary care

physicians to care for underserved populations in both urban and rural areas and

are more likely to care for Medicaid recipients.

Community health centers play a major role in providing primary care to both

urban and rural underserved communities. The number of community health

centers has grown from 730 in 2000 to 1,300 in 2014, serving 23 million patients at

9,000 sites.

The average community health center has better rates of providing

preventive care (immunizations, mammograms, colorectal cancer screening) and

also has better rates of diabetes and hypertension control than average rates for

the US population.

48,49

However, community health centers report shortages of

primary care practitioners and registered nurses and have difﬁculty recruiting these

professionals.

PRIMARY CARE PAYMENT REFORM

(ALSO SEE APPENDIX)

For decades, health care reformers have tried to move the healthcare system

away from fee-for-service—which rewards only volume—toward payments that

encourage value (deﬁned as better care at lower cost). Several recent initiatives,

some of which are features of the Affordable Care Act, attempt to change payment

for primary care and may impact the primary care RN workforce. Primary care

practices paid under fee-for-service may provide unnecessary care and may not

focus sufﬁciently on chronic and preventive care.

High-value services performed

by non-practitioner team members—RNs, for example, providing intensive

management of patients with complex healthcare needs as well as health education

and coaching, and care coordination—are rarely compensated under fee-for-service

payment. In 2015, a number of alternative payment models that would support

services provided by RNs are under discussion and are being piloted by payers and

healthcare providers.

In January 2015, the US Department of Health and Human Services (HHS)

announced plans to tie future Medicare payments to value. If such new payment

models are broadly implemented, they may give primary care practices the

ﬂexibility needed to deliver team-based care, since payment will no longer be tied

to the practitioner face-to-face visit.

The Appendix at the end of this paper displays the wide range of payment models

and their possible impact on primary care nursing. Traditional fee-for-service does

not support RNs in primary care settings since few of their services are reimbursed.

In the past several years, Medicare has introduced some fee-for-service add-

on payments: for wellness visits and complex care management, for example.

In addition, some insurers and provider organizations have added lump-sum

payments—pay for performance and patient-centered medical home rewards—on

top of fee-for-service to support team care by non-practitioner clinicians. These

add-on payment options can generate extra revenue to support RNs on the

primary care team.

The trend toward accountable care organizations (ACOs) may usher in a more

fundamental payment change through its promise of shared savings dollars, some

of which could come to primary care if the ACO reduces costly hospitalizations

while maintaining quality. Registered nursing skills that emphasize intensive

ambulatory care for high-utilizing patients and improved coordination across

primary care, acute hospital admissions, long-term care, and home care are well

aligned with ACO goals.

Integrated and globally budgeted healthcare systems—such as Geisinger, Mayo

Clinic, the Veterans Administration, and Kaiser Permanente—currently have the

greatest ﬂexibility to support team-based care, including enhanced roles for RNs.

The most far-reaching primary care payment reform proposal provides risk-adjusted

global payments for delivering comprehensive primary care, with additional

payments for high performance.

Yet the road to payment reform may be long and winding.

In 2013, only 7% of

physicians supported moving away from fee-for-service. Only 29% of physician-run

ACOs and 20% of hospital-run ACOs have produced savings, and only a trickle of

those savings came to primary care.

PRACTITIONER BURNOUT

Burnout among PCPs has become a disturbing phenomenon in primary care

practice. Burnout is a syndrome of emotional exhaustion, loss of meaning in work,

feelings of ineffectiveness, and a tendency to view people as objects rather than

as human beings. In a 2014 national survey, 63% of family physicians, 60% of

general internists, and 46% of general pediatricians reported symptoms of burnout,

a signiﬁcant increase from 2011.

While research on burnout has focused on

physicians, a recent study found that primary care nurse practitioners and physician

assistants also experience burnout.

Physicians who have burnout are more likely

to report making medical errors, score lower on instruments measuring empathy,

and plan to retire early while their patients are less satisﬁed and have reduced

adherence to treatment plans.

Major contributors to burnout include dysfunctional

EMR systems, which greatly increase documentation time; insufﬁcient time with

patients; the quantity and pace of work; loss of control over practice conditions;

and onerous rules from payers and regulators.

RN burnout has been studied in hospitals and nursing homes where it is a

signiﬁcant factor.

60,61

Interviews with RNs in over 30 primary care practices revealed

that RNs spending their entire day in triage and in-box message management had

symptoms of burnout, whereas RNs empowered by standing orders to contribute

meaningfully to patients’ care generally enjoyed their jobs.

Group Health Cooperative in Seattle ameliorated physician burnout by reducing

panel size and increasing visit length;

however, those changes are difﬁcult to

sustain and spread because of the shortage of primary care practitioners. Well-

functioning teams can also reduce practitioner burnout.

However, the most

common response to burnout is the increase in part-time primary care practice.

THE SOCIAL MOVEMENT TO REJUVENATE

PRIMARY CARE

Since the 1990s, a cluster of organizations, including the Institute for Healthcare

Improvement (IHI), MacColl Center for Health Care Innovation, and the Robert

Wood Johnson Foundation, have led efforts to assist primary care practices

improve their patient-centeredness, access, chronic illness care, and overall practice

organization.

In 2007, leaders at the IBM Corporation brought together the four

primary care professional organizations—American Academy of Family Physicians,

American College of Physicians, American Academy of Pediatrics, and American

Osteopathic Association—to draft principles of the “patient-centered medical

home (PCMH)”.

Further, national, regional, and state-wide collaboratives sprang up, bringing

practices together to utilize the IHI’s Model for Improvement, adopt elements of

the chronic care model, and set up information systems to track performance.

By 2010, several organizations, including the National Committee on Quality

Assurance (NCQA), MacColl Center, UCSF Center for Excellence in Primary Care,

and others, created models synthesizing the common features of high-performing

primary care. One such model, the 10 Building Blocks of High-Performing Primary

Care [see ﬁgure], is based on observations made at 23 excellent primary care

practices around the United States.

NCQA bestows public recognition upon practices that meet certain quality

criteria.

Some payers offer ﬁnancial rewards to practices gaining NCQA

recognition. Many practices initiated the integration of primary care and behavioral

health. Some have added acupuncture, meditation, yoga, and other non-traditional

services. Small practices with insufﬁcient resources to qualify as a PCMH can utilize

personnel in their medical neighborhood—for example, hospitals, health plans, or

independent practice associations—to increase their capacity for improvement.

Primary Care Progress, with over 40 chapters at health science schools, spreads

enthusiasm among students and residents to pursue primary care careers. The

Comprehensive Primary Care Initiative is a multi-payer effort to strengthen

primary care through revenue enhancements for practices that offer chronic care

management, access and continuity, preventive care, and coordination of care

across the medical neighborhood.

Figure: The 10 Building Blocks of High-Performing Primary Care

Engaged

leadership

Data-driven

improvement

Empanelment

Team-based

care

Continuity

of care

Comprehensive-

ness and Care

Coordination

Template of

the future

Population

management

Patient-team

partnership

Prompt

access to care

Two diverging trends are buffeting primary care. On the one hand, stressors like

large panel sizes, productivity demands to see more patients each day, EMR-

induced documentation creep, and escalating pressure to improve performance

metrics without additional resources are causing PCP dissatisfaction and burnout.

On the other hand, practitioners are feeling the excitement and challenge of

implementing a new team-based care model. Some practices tend toward the

negative pole, others toward the positive, and many exhibit both tendencies at the

same time.

NON-TRADITIONAL PRIMARY CARE MODELS

Several new models of primary care practice have emerged, including direct

primary care, concierge practices, retail clinics, and nurse managed health clinics.

The direct primary care model features smaller panels, longer visits, few or no

non-practitioner team members, and low overhead expenses. Most of these

practices do not accept insurance payments; instead, patients pay a monthly fee of

$100 on average. Some practices also charge per-visit fees, averaging $15. Direct

primary care patients often have high-deductible insurance to help cover specialty

and hospital care. In 2014, an estimated 150 direct primary care practices with

275 locations were operating in 40 states.

The number of direct primary care

physicians is growing rapidly, from 150 in 2005 to 4,400 in 2014.

Concierge practices are direct primary care practices, but with high fees (ranging

from $200 to $2,000 per month), panels as low as 500 patients, and 24/7 physician

accessibility. Their growth is limited by the size of the population able to afford this

luxury approach.

For physicians, this model is the perfect antidote to burnout.

But for the general population, concierge practices—with their small panel sizes—

exacerbate the primary care practitioner shortage. In addition, practices converting

from a traditional model—with panels of 2,000 patients—to a concierge model

discharge many of their patients, generally those who cannot afford the fees or

whom the practice considers “difﬁcult.” Discharged patients may have trouble

ﬁnding nearby practices accepting new patients.

Another primary care model is the retail clinic, featuring pharmacies and other

retail chains hiring nurse practitioners to work in their stores, seeing patients for

uncomplicated respiratory or urinary tract infections, conjunctivitis, immunizations,

and preventive care. Facing large insurance deductibles, patients can receive

accessible care for relatively small sums in convenient locations. Those who

present with more complex problems are sent to their primary care practice or an

emergency room.

The number of retail clinics grew from 300 in 2007 to 1,900

in 2015 and may increase to 3,000 by 2016.

The majority of retail clinics are

operated by the CVS and Walgreens drug store chains. Walmart, with 4,500 stores

nationwide, is planning a major expansion of retail clinics, including the care of

hypertension and elevated cholesterol.

Increasingly, retail clinics are entering

into partnerships with health systems such as the Cleveland Clinic and Kaiser

Permanente, allowing coordination with primary care practices.

Yet another model is the urgent care center—generally staffed by a physician and/

or physician assistant—which provides episodic walk-in services with extended

hours, usually open seven days per week from 8 a.m. to 8 p.m. With x-ray services

on-site, urgent care centers typically treat acute injuries such as lacerations, sprains,

and fractures, but also provide laboratory services, immunizations, sports physicals,

and pain management.

About 9,000 urgent care centers were functioning in 2012,

owned by physicians, urgent care chains, or hospitals.

THE ROLE OF TECHNOLOGY

The adoption of electronic technologies is gradually transforming primary care. The

following list is but a sampling of technologic opportunities for primary care:

• E-mail encounters through patient portals are replacing face-to-face visits

and can be used for chronic disease management.

77,78

• Using mobile devices for patient education and self-monitoring of exercise

and diet is starting to show promise.

• Routine clinical processes, such as prescription reﬁlls and panel

management, can be performed using computer algorithms without taking

the time of practitioners or other team members.

• Telehealth innovations allow practitioners and registered nurses to remain

in their ofﬁces and check in regularly with patients at home with such

conditions as congestive heart failure and hypertension.

• Patients taking and sending digital photos of skin rashes can receive

dermatologic care from their homes.

• Telehealth interactions among practitioners allow PCPs to access specialists

for such conditions as HIV/AIDS, hepatitis C, and mental health conditions.

• New Mexico’s ECHO videoconferencing program hosts clinician education

case conferences, bringing together remote practices with the university

medical center.

81,82

THE FUTURE OF TEAMS IN PRIMARY CARE

Primary care practitioners are challenged to provide excellent care for their large

panels of increasingly complex patients. Teams are needed to create more primary

care capacity without increasing clinician work.

High-performing primary care

practices are forging teams that share the care, reserving the time of PCPs to

provide diagnosis and treatment while utilizing non-practitioner clinicians for

chronic disease management, health coaching, care coordination with the medical

neighborhood, EMR documentation (scribing), and panel management to ensure

that all patients are offered all recommended routine preventive and chronic care

services.

84,85

In a number of practices, registered nurses play important team roles,

in particular providing patient education and coaching to improve the health

behaviors and medication adherence of patients with chronic conditions, and

leading specialized teams for the management of complex patients with multiple

diagnoses.

However, teams have been a major challenge for the majority of practices. The

low level of reimbursement received by primary care and the predominance of

practitioner-only fee-for-service payment makes it difﬁcult for practices to hire

sufﬁcient staff to populate teams. In order to infuse primary care with a team-

based paradigm, health professional schools will need to solidify a commitment to

interprofessional education

such that young practitioners, nurses, pharmacists,

and other team members enter their careers with competencies and attitudes

allowing teams to prosper.

ENHANCED RN ROLES IN PRIMARY CARE

Registered nurses represent the largest health profession in the United States,

almost three million in 2012, with 61% working in hospitals. Less than 10% of RNs

work in ambulatory care. During the 1990s, the number of new RN entrants fell

sharply, leading to projections of a serious RN shortage. Yet from 2000 to 2010,

the number of RNs entering the workforce each year doubled.

The number of RN

jobs is projected to grow by 16% from 2014 to 2024,

in particular because of the

growth of the elderly and chronically ill populations.

As practice size continues to grow, as more practices are owned by hospital

systems, and as the wave of chronic disease prevalence engulfs primary care,

it is likely that registered nurses will play an increasingly central role in primary

care. Small, physician-owned practices rarely hire RNs; personnel supporting

practitioners are almost universally unlicensed medical assistants.

While practices

in larger health systems and community health centers also utilize medical

assistants, they are increasingly hiring RNs. Currently, primary care RNs spend much

of their time triaging patients requesting same-day care; addressing EMR inbox

messages; and performing ofﬁce functions, such as injections, wound care, and

patient education.

Practices initiating team models are beginning to engage RNs in four new major

responsibilities: 1) managing chronic disease patients using protocols (e.g.,

titrating blood pressure medications or adjusting diabetes medications according

to pre-approved algorithms); 2) leading complex care management teams to

help improve the care and reduce the costs of high-utilizing, multi-diagnosis

patients; 3) coordinating care between the primary care practice and the medical

neighborhood surrounding the practice;

and 4) assisting practitioners to conduct

acute patient visits for such conditions as respiratory infections and urinary tract

infections (“co-visits” or “ﬂip-visits”).

In these delivery models, the responsibility

for the health of a patient panel is shared among team members, who are

empowered to provide care independently of primary care practitioners.

92,93

2015, some of these enhanced roles were well on their way; for example, 43% of

US physicians reported that their practice uses nurses or case managers to manage

care for patients with chronic conditions.

13,94

The American Association of Ambulatory Care Nursing (AAACN) predicts that the

decline in hospital admissions and the growing importance of ambulatory care

are propelling a shift in health services, moving from the hospital to ambulatory

care settings. The heightened complexity of ambulatory patients and greater

expectations for quality require personnel with higher levels of clinical training than

that possessed by medical assistants, and the new medical home models advocate

for RNs to take on chronic care management and care coordination. The AAACN

has created a core curriculum for ambulatory nursing.

Obstacles to the growth of enhanced RN roles in primary care are the continued

predominance of fee-for-service payment, hospital systems’ overly cautious

interpretations of scope of practice regulations, and the lack of adequate training

in primary care nursing.

In addition, with the growing importance of nurse

practitioners as primary care practitioners, the precise roles of NPs and RNs need

to be carefully delineated. Finally, because patient access to primary care remains

a challenge, primary care RNs are spending a great deal of their time doing triage;

to re-allocate their responsibilities toward chronic care management and care

coordination, primary care practices will need to ﬁgure out how to relieve RNs of

their triage duties.

CONCLUSION

Primary care is undergoing profound change in many areas: practice size and

ownership; public expectations for quality, access, and patient-centeredness;

the nature of the clinician workforce as NPs and PAs increase in numbers relative

to physicians; the growth of chronic illness and particularly complex, high-cost

chronic illness; the crisis in care coordination due to the separation of hospital and

ambulatory physicians; the increase in primary care practitioner dissatisfaction and

burnout resulting in part from the cascade of documentation demands brought on

by the EMR; and the potential (though uncertain) of primary care payment reform

that would facilitate team-based care.

Like the general population, primary care is expected to become increasingly

stratiﬁed.

High-income people are likely to receive care in direct primary care/

concierge practices with small panel sizes. The middle class will receive primary

care predominantly within large health systems that are increasingly swallowing

up independent primary care ofﬁces. Such care will feature overly short primary

care visits—necessitated by large panel sizes—often with NPs/PAs or other team

members or through electronic patient portals, with continuity of care undermined

by increasingly part-time clinicians and empathic care challenged by high levels of

clinician burnout. Lower-income, vulnerable populations will likely receive primary

care in busy community health centers and public hospital systems, a number

of which provide excellent care because of engaged leadership and the social

commitment of their practitioners and staff.

Particularly in larger practices and community health centers, the transformation

of primary care creates favorable conditions for growth in the number of RNs,

with their likely roles focused on chronic care management; the management of

complex, high-utilizing patients; and the coordination of care among hospital, long-

term care, ambulatory care, and home. The barriers to such a development are the

cost of RN salaries and beneﬁts, the lack of RN reimbursement, and the reality that

most RNs have not received education or training in primary care competencies.

In order for RNs to become highly valued team members in primary care practices,

nursing education will need to place greater priority on the training of RNs for

primary care careers.

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101. Mechanic RE. Mandatory Medicare bundled payment—is it ready for prime

time? N Engl J Med 2015;373:1291-1293.

Appendix

Payment Reform and Potential Impact on Primary Care Nursing

Payment

Model

FFS-

Based or

Replaces

FFS

Current/Projected Status of

New Payment Methods

Likelihood of

Primary Care

Hiring Rns

FEE-FOR-SERVICE

Fee-for-

service (FFS)

FFS Still the predominant payment

mechanism. Practitioners are

reimbursed for each service they

provide and pay is not linked

to outcomes. FFS is a well-

recognized driver of health care

costs and does not support team-

based care, including registered

nurses on the team.

Low likelihood

of more RN

hiring

FEE-FOR-SERVICE PLUS VALUE-BASED INCENTIVES

Medicare

wellness

visits

FFS-based

new code

In January 2011, Medicare

introduced the annual wellness

visit to promote wellness and

care coordination through a

health risk assessment, medical

and family history, and functional

status review. Licensed care team

members other than PCPs can

conduct the visit and bill for the

service.

Increased

likelihood of

RNs

Medicare

chronic care

payments

FFS-based

new code

New non-visit-based Medicare

chronic care management

payments took effect in January

2015. Simulation models show

that practices can expect

approximately $332 per

enrolled patient per year if a

registered nurse delivers the care

management. At minimum, 131

Medicare patients must enroll

for practices to break even when

hiring a full-time RN to provide

these services.

Increased

likelihood of

RNs

Merit-based

Incentive

Payment

System

(MIPS) for

physicians

under

MACRA

FFS-based

Pay-for-

perfor-

mance

The Medicare Access and CHIP

Reauthorization Act of 2015

(MACRA) gives physicians two

options for payment under

Medicare: the Merit-Based

Incentive Payment System

(MIPS) or an Alternative Payment

Mechanism (APM). MIPS adjusts

physician fees up or down based

on measures of quality and

resource use. The legislation is

designed to be budget neutral

and will increase or lower

physician payments from 4–9%

starting in 2019.

97,98

May increase

the need for

registered

nurses if they

are used to

increase quality

Hospital

re-admission

payment

penalties

FFS-based

penalties

for

unneeded

readmis-

sions

The Hospital Readmission

Reduction Program (HRRP),

started in October 2012, reduces

payments to hospitals if they have

higher than expected 30-day

readmission rates for selected

conditions. Interventions

to reduce readmissions are

primarily funded by hospitals

through nurse care management

programs.

Primary care

practices run

by hospitals

may hire RNs

to help reduce

re-admits. Many

transitional

care programs

use RNs or

advanced

practice nurses.

Payment

Model

FFS-

Based or

Replaces

FFS

Current/Projected Status of

New Payment Methods

Likelihood of

Primary Care

Hiring Rns

FEE-FOR-SERVICE PLUS VALUE-BASED INCENTIVES (CONT.)

Appendix

Payment Reform and Potential Impact on Primary Care Nursing (Continued)

PATIENT CENTERED MEDICAL HOME MODELS

Advanced

primary

care (APC)

initiatives

FFS add-

on or

population-

based

payments

CMS is currently seeking input

on initiatives to test innovations

in advanced primary care,

focusing on improving care of

complex patients, facilitating

care coordination, and moving

away from encounter-based

payments towards population

based payments.

100

APC payments

support team-

based care and

could increase

primary care RN

hiring.

Comprehen-

sive Primary

Care

Initiative

FFS-based

care mgmt

fee and

shared

savings

A 4-year multi-payer initiative

(2012-2016) to strengthen

primary care in 7 US regions.

Participating practices

receive funding through a

$20 PMPM care management

fee and an opportunity to

share in net savings to the

Medicare program. Focuses

on practice redesign for

access improvement, planned

chronic care, complex

care management, patient

engagement and care

coordination.

If the care

management

fee payment and

shared savings

are large enough,

these models may

increase RN hiring

in primary care

ALTERNATIVE PAYMENT MODELS FOR PHYSICIANS

Alternative

Payment

Models

under

MACRA

Can be FFS

or replace

FFS

Under MACRA, physicians

can choose to receive

Medicare payments through

an Alternative Payment Model

(APM) rather than through MIPS

(see above). The precise nature

of the APMs are not speciﬁed,

but they must reward value, not

only volume of care provided.

APMs can

incentivize RN

hiring in primary

care

Payment

Model

FFS-

Based or

Replaces

FFS

Current/Projected Status of

New Payment Methods

Likelihood of

Primary Care

Hiring Rns

Payment

Model

FFS-

Based or

Replaces

FFS

Current/Projected Status of

New Payment Methods

Likelihood of

Primary Care

Hiring Rns

ACCOUNTABLE CARE ORGANIZATION (ACO) MODELS

Shared

savings

models

(one-sided

risk)

Can be FFS

or replace

FFS

Often combined with fee-for-

service, P4P, bundled payments,

global payments or capitation,

HHS is encouraging the growth

of ACOs, organizations that

take responsibility for the care

and costs of a population of

patients. ACOs generally bring

hospitals and physician practices

under one organizational

umbrella. ACOs that reduce

total costs of care for its

population of patients receive

part of the savings, some of

which could go to primary care

as non-FFS payments. and can

reward primary care practices as

non-FFS payments.

52,97,99

ACOs

assuming one-sided risk do not

pay back money if their costs

increase.

If payments to

primary care

practices are

sufﬁcient to

pay for new

team members,

registered

nurses could be

used to support

chronic care

management,

complex care

management,and

care coordination.

Shared

savings

models (two-

sided risk)

Can be FFS

or replace

FFS

ACOs assuming two-sided risk

receive a greater percentage

of shared savings if their costs

decrease, but must pay back

money if their costs increase.

Two-sided risk

provides higher

potential for

shared savings

but also greater

risk for losing

money.

BUNDLED PAYMENTS

Bundled

payment

Not FFS As of 2013, providers can

voluntarily apply for one of

four CMS models for bundled

payments for about 48 conditions

under the Bundled Payments

for Care Improvement Initiative

(BPCI). CMS is proposing to

launch its ﬁrst mandatory

bundled payment for joint

replacements (hip and knee) in 75

metro areas starting in starting in

January 2016.

101

Has minimal

impact on

primary care

since most

bundled

payments are

for surgical and

post acute care.

PARTIAL OR FULLY INTEGRATED SYSTEMS

Provider-

sponsored

health plans

Not FFS Provider networks, usually led by

a hospital system, assume 100%

of the ﬁnancial risk for insuring

the patient population. They

collect premiums directly from

employers or individuals, and

have control and ﬂexibility over

how much is spent on delivering

care. Examples are Geisinger

Health Plan, Providence Health

Plan, and Care Oregon.

This model has

the highest

amount of

ﬂexibility to

support team-

based care.

Integrated

systems

Not FFS Globally budgeted primary care

practices

and systems such as

Kaiser, the Mayo Clinic and the

Veterans Administration provide

services through the health care

continuum, and are incentivized

to keep patients healthy to

reduce high-cost specialty and

tertiary care.

These systems

may use RNs for

complex care

management

and care

coordination.

Appendix

Payment Reform and Potential Impact on Primary Care Nursing (Continued)

Payment

Model

FFS-

Based or

Replaces

FFS

Current/Projected Status of

New Payment Methods

Likelihood of

Primary Care

Hiring Rns

REGISTERED NURSES

IN PRIMARY CARE

STRATEGIES THAT SUPPORT

PRACTICE AT THE FULL SCOPE OF

THE REGISTERED NURSE LICENSE

A Message from the Authors: Our interest and expertise in addressing this topic

stems from our deep collective experience as nurses, leaders, and executives

in primary care and primary care transformation. Mary Blankson is chief nurse

ofﬁcer for Community Health Center, Inc. (CHCI). Margaret Flinter is senior vice

president and clinical director of CHCI, founder emeritus of its Weitzman Institute

for Research and Innovation in Primary Care, and national co-director of the LEAP

project. Maryjoan Ladden is a senior program ofﬁcer at the Robert Wood Johnson

Foundation, where she led the conceptual development of the LEAP Project.

All three are doctorally prepared nurses, certiﬁed nurse practitioners, advanced

practice registered nurses, and are engaged nationally to advance primary care

transformation. Many of the innovations described in this paper reﬂect original work

done at CHCI or practices identiﬁed in the LEAP project.

INTRODUCTION

The United States is entering a new era of primary care inspired by greater access

to care spurred by the passage of the Affordable Care Act (ACA). This increased

access has led to the lowest number of uninsured Americans since records have

been kept, and greater effectiveness of care made possible by new technologies,

Commissioned Paper

MARGARET FLINTER, APRN, PhD

MARY BLANKSON, APRN, DNP

MARYJOAN LADDEN, APRN, PhD

science, and treatments. The aim of better, safer, higher quality care that is

satisfying to both patients and providers, and affordable to individuals and society,

may well be within our reach. To reach these goals, we must effectively use every

bit of human capital available in the primary healthcare system. This is the backdrop

against which we pose the questions: what strategies are most effective to support

the full scope of registered nurse (RN) practice in primary care? And, how do we

create a future state in which this RN role development will continue and ﬂourish?

Over the past decade, the national conversation on access has expanded to include

the question: access to what? This focus on the effectiveness of primary care in

improving overall health, as measured by speciﬁc health outcomes, has primarily

emphasized the contributions of primary care providers of all types (physicians

[MDs]; physician assistants [PAs]; and advance practice registered nurses [APRNs])

and lamented the perceived shortage and maldistribution, as well as the widely

reported dissatisfactions of primary care providers, particularly physicians. Despite

the varied conversations focused on provider-level and provider-centric solutions

and interventions to improve primary care delivery, the discussion is beginning to

include the expanded care team, which, in fact, multiplies not just the hands doing

the work, but broadens the skill base by expanding the variety of individuals on the

team.

The patient-centered medical home (PCMH) movement has highlighted the

importance of team-based care and the critical roles that all members of the

team—providers; professional staff, such as registered nurses, behaviorists,

pharmacists, and social workers; and other certiﬁed or non-certiﬁed staff, such as

medical assistants, health coaches, and receptionists/patient service associates—

play in a well-functioning PCMH striving to achieve the Triple (or quadruple) Aim.

All of this has led many exemplar practices, particularly those that have sought and

achieved PCMH status, with its emphasis on improved access, patient activation/

self-management, education, empanelment, and chronic illness care, to reconsider

the RN role in primary care. These practices have carefully examined how using

interdisciplinary teams containing health professionals and other staff will help them

achieve the quadruple aim. Increasingly, they have recognized the expertise and

versatility of the RN and the value this role brings in increasing access, capacity,

clinical depth, vitality, and even revenue generation.

THE EVOLVING RN ROLE IN PRIMARY CARE

The evolution and broadening of the RN role in primary care, not surprisingly,

is also tied to the structure and organization of the practice from a ﬁnancial/

payment perspective, such as the cost of investing in RNs as well as the potential

savings that may accrue from RN care. In sites where the investment in RNs is a

direct expense to the bottom line and impacts the personal compensation of an

owner/group of owners, as is the case with physician-owned practices, there may

be more reluctance to invest in the RN role. In community health centers, health

maintenance organizations (HMOs), and accountable care organizations (ACOs),

where all staff are salaried employees, there may be more willingness to employ

and invest in RNs on the primary care team. In integrated care systems and HMOs,

the ﬁnancial savings achieved by decreased emergency room (ER) utilization or even

modest reductions in hospital readmissions and effective chronic care management

through an investment in expanded primary care nursing are a potential windfall,

though they may not be directly attributable to speciﬁc care provided by RNs.

National nursing workforce trends and employment opportunities suggest a

growing recognition of the opportunities for and value of RN roles in primary/

ambulatory care as well as in outpatient surgery, specialty care, long-term care,

public health departments, and positions within the larger healthcare industry,

such as insurers/payers. At the same time, based on 2012 data, there will be an

actual projected excess of the RN supply relative to demand nationwide by 2025,

although 16 states are still projected to have a shortage.

This excess of supply

over demand persists even when taking into account the projected retirement of

signiﬁcant numbers of nurses, and reﬂects the near doubling of production of new

RNs in recent years.

The ACA is designed to expand the number of people with

health insurance coverage and to encourage new value-based models of care, but

it is too early to know whether these emerging models will contribute to a new

growth in demand for nurses, and new roles in prevention and care coordination.

This is an important addition to the conversation regarding nursing workforce as

it could impact the validity of the published projections, particularly if new and

expanded roles become the norm. It is prudent to not become distracted with the

“good news” of adequate workforce and to instead continue to maintain focus on

better molding the nursing workforce to ﬁt the demands of the newly insured, and

to continue to improve quality, safety, and efﬁciency, as was suggested by Buerhaus

and his colleagues.

The current state of nursing in primary care has been described qualitatively

in practices that use RNs in new and different ways. A study of 16 exemplar

practices using RNs in primary care focused on three major domains (episodic

and preventive care, chronic disease management, and practice operations) that

spanned functional areas of triage, documentation of health status, chronic illness

management, hospital transition management, delegated care for illness, health

coaching, supervision of other staff, and quality improvement (QI) leadership.

Similarly, Bodenheimer and colleagues

identiﬁed 21 potential exemplar practices

and interviewed representatives at 13, including federally qualiﬁed health centers

(FQHCs), integrated health systems, and county health systems. They identiﬁed

many roles and domains in common with Smolowitz and colleagues.

Their report

identiﬁed key barriers to advancing the practice of RNs in primary care, and made

recommendations for ameliorating practice restrictions, and for advancing role

expansion for RNs in primary care.

These barriers include the perceived high cost

of RNs, perceived lack of opportunity to bill and generate revenue to support

RN positions, lack of education and training in primary care at the university level

to prepare RNs for practice, and failure to free RNs up from the constraints of

managing triage.

A Robert Wood Johnson Foundation (RWJF) initiative, The Primary Care Team:

Learning from Effective Ambulatory Practices, or LEAP (www.improvingprimarycare.

org),

also studied exemplar team-based practices across the country in a wide

range of settings and systems (rural and urban, large and small, solo practice,

FQHC, academic practice, integrated health systems). Preliminary review of

the data suggests agreement with the themes found in other studies, but also

a wide variability in the advancement of RN practice in primary care.

While in

some practices, RNs were still tied to telephone triage; in others, RNs were more

effectively engaged in delivering routine preventive and episodic care along with

the primary care provider (PCP), delivering care independently through delegated

and standing orders, and playing a strong leadership role in practice operations,

team leadership, and QI.

The RN role has also been qualitatively examined in community health center

practices

as well as the Veterans Administration (VA), which has advanced the role

of RNs in primary care through the patient-aligned care team (PACT) model,

7,8

and

Kaiser Permanente.

9,10

A common theme is that, while these very busy practices

value RN care and have a commitment to RN care management and coordination,

in reality, they have little time for these areas given the demands of daily practice.

These large practice systems argue for the signiﬁcant impact and contribution

of RNs in primary care, particularly in chronic disease management, transition

management, and patient education, while recognizing that there are few data

to demonstrate the speciﬁc role that RNs play in improving patient and/or

practice outcomes. Recognizing the lack of speciﬁc data, a recent Canadian

Nurses Association report recommended an up-to-date and comprehensive

description of the number, characteristics, or practice patterns of Canadian

nurses in primary care.

RNs have always played an important role in prevention, health education/

health promotion, and family support. The very roots of community health/public

health nursing in the US are based in this work. What is different today is the

potential for these roles to be re-imagined and better scaffolded to be dynamic,

interdisciplinary, data-driven, evidence-based roles and activities that can be

measured in terms of their contribution to patient outcomes, cost savings, and

team vitality.

In the following sections, we will 1) identify components of the effective RN role on

the integrated primary care team; 2) identify the factors that will advance practice

from isolated exemplars to an evidence-based national standard of effective RN

primary care practice to which we train and educate the next generation; and

3) envision a future in which RNs in primary care will contribute in new roles to

individual and population health outcomes and team vitality. Our work presumes

that, at a minimum, primary care practices have evolved to include at least a

rudimentary team-based approach to care, have an electronic health record, and

are engaged in some level of monitoring of outcomes and improvement work either

independently at the practice level or as part of a larger system.

MAXIMIZING THE RN ROLE IN PRIMARY CARE

Even as the national payment discussion focuses on paying for value rather than

volume, those at the front lines of primary care know that “volume” is not just

a marker for fee-for-service payment methodologies. It is a marker for very real

people, populations, and communities in need of a primary care provider and

primary care services. Volume can be expressed in terms of the numbers of

individuals seeking access to a PCP for in-person and electronic visits, and “in-

between visit” contacts for follow up and care coordination.

One study estimated that the standard panel size of 2,500 patients would take

approximately 21.7 hours per day for a PCP to manage.

In our experience, a

full-time PCP can, at best, meet the care demands of a panel of 1,500 patients,

depending on the amount of care that is shared with other team members. In order

to increase the provider’s panel capacity, professional and lay staff must be trained

and used effectively to deliver some of the visits completely and independently and

to help manage the preventive, episodic, and chronic illness needs of the patients

on the panel.

It follows logically that practice systems that utilize the RN in primary care to

the full extent of the RN’s education and experience—and provide appropriate

guidelines, supports, and supervision to ensure practice is within the scope of the

RN license—create additional visit and patient engagement capacity, and thus

panel size capacity. This enhanced participation by the RN contributes to increased

access for existing patients, a more satisfying experience for patients, the potential

for improved chronic illness clinical outcomes, cost savings through reduced ER

encounters and hospitalizations, and ultimately, healthier communities. Several

key roles—panel management, managing acute and chronic illness, complex care

management, and QI—maximize the RN’s impact on and value to the practice.

ACUTE AND CHRONIC “IN-BETWEEN” VISITS

INDEPENDENTLY PERFORMED BY RNS

Empanelment is fundamental to a PCMH.

All patients in a practice must be

assigned to a PCP—whether an MD, APRN, or PA—and the practice must be able

to reliably monitor the panel size and sub-populations within the panel, such as

patients with speciﬁc chronic illnesses or high acuity needs. Standing orders help

the team identify and manage speciﬁc health problems, complaints, or conditions

that can be reliably, safely, and satisfyingly addressed and treated through

application of guidelines to a particular population of patients. These are pre-

determined by a licensed independent medical provider or by the consensus of a

group of providers, and carried out on behalf of the authorized provider, and “as if”

the provider were delivering the visit. Management of common episodic conditions,

such as urinary tract infection (UTI), sore throat, and some sexually transmitted

diseases (STDs), by standing order has been common in primary care practice.

The list of conditions has now expanded to include healthcare encounters not just

in which there is minimal differential diagnostic consideration, but also in which

patients stand to beneﬁt from the RN’s focus on education and self-management

as well as treatment. These include contraceptive management and emergency

contraception for unplanned pregnancies, latent tuberculosis treatment, chronic

illness monitoring, and chronic pain assessment and medication surveillance.

Another example is a more comprehensive visit, such as an annual diabetes visit

at which all related measures are reviewed, or the prenatal care intake visit. These

visits may last 45 minutes, be comprehensive in scope, provide both patient

and practice team an opportunity for a full review, discussion of concerns, and

update on preventive and periodic measures (diabetic retinal exam, vaccines, self-

management goal setting, foot exam).

When developed by the appropriate clinician (chief medical ofﬁcer in a large

system; the supervising provider in a small system), standing orders must be clear

in terms of explanations and expectations, reﬂect evidence-based practice, and

ﬁnally, clearly state that the activity called for under the standing order is done

by the RN, under the authority of the provider. The standing order is unique to a

speciﬁc health condition or complaint, not to the individual patient. When RNs are

able to practice using standing orders, the PCPs and other professional and lay staff

can attend to other patient issues, and the PCP’s panel and the practice size and

capacity is increased as a result.

Compared with standing order sets, delegated order sets are speciﬁc to the

individual patient, and allow the PCP to have his/her plan of action, adjusted by

evolving data, carried out over a period of time, until the next needed PCP follow

up visit. Delegated order sets are most often used in the management of chronic

illness, particularly when treatment is being initiated or modiﬁed, and the patient’s

response—personal, clinical, and social—is of paramount importance.

An example of this would be the patient with diabetes for whom the PCP initiates

insulin. Frequent visits with the RN are used to assess the patient’s medication

response and titrate dosing according to a pre-set plan; educate and support the

patient/family in making the necessary changes; and spearhead coordination with

other members of the team, such as a certiﬁed diabetic educator (CDE), registered

dietician (RD), health coach, or outside specialty provider. Similarly the uncontrolled

hypertensive patient would beneﬁt from RN-supported medication monitoring

and titration, organizational and tracking support for home monitoring of blood

pressure, motivational interviewing and self-management goal support and, as with

diabetes, coordination with both internal and external specialists who can assist in

the overall patient care plan.

In behavioral health care, nurses can assist both PCPs and psychiatry teams by

monitoring for adherence and response to psychotropic medications in between

visits. This not only increases patient support but also expands the panel size

capacity that psychiatry MDs and APRNs can manage by increasing the time

between direct prescriber follow-up visits. When a new medication is started,

patients may encounter barriers, from difﬁculty purchasing the medicine to

experiencing bothersome side effects. The primary care RN can intervene to

alleviate barriers to initiating and adhering to the regimen, rectify and address early

reactions or side effects in collaboration with the prescriber, and monitor early

medication impact to the desired symptom as well as titrate dosage in accord with

the delegated order set.

While RNs have the capability to multiply the impact of the PCP and other care

team members by delivering evidence-based interventions that are speciﬁc

either to the population (standing orders) or patient (delegated orders), many

new RNs do not receive education and training speciﬁc to such domains during

their academic preparation. Likewise, many experienced RNs are not prepared to

assume these new, more proactive and independent roles since they come from an

acute care framework, which is typically order driven. As the RN role continues to

expand, practices must also take responsibility for ensuring that training, support,

and ongoing education and coaching are in place to master both new roles, as well

as content knowledge necessary to expertly execute these roles.

PREVENTIVE SERVICES AND

POPULATION/PANEL MANAGEMENT

There are many deﬁnitions that describe the actions of “planned care” and “panel

management.” They can be generally described as the act of making sure that all

patients in the panel receive the required chronic and preventive routine evidence-

based services, based on either their age, gender, chronic illness, or other deﬁned

category of risk. These services include things like routine cancer screening or even

routine diabetes care, such as foot checks and retinal screening. This role certainly

can be completed by RNs, but also generally can be completed by medical

assistants (MAs). This is an important distinction given the goal of ensuring that RNs

are able to practice at the top of their license in order to expand access for patients

to more comprehensive care without further stressing provider team members.

COMPLEX CARE MANAGEMENT AND

TRANSITIONS OF CARE

In the same way, coordinating the care of patients is fundamental to the role of

nursing, but also can be managed by many members of the team, including non-

licensed case managers, social workers, and lay health workers. However, complex

care management (CCM) is not about coordinating the details of care provided

by numerous people, but about managing the care of a deﬁned sub-population

of one or more panels, and ensuring a solid grounding of the overall care plan

in evidence-based clinical practice interventions. This population may, and often

does, include patients experiencing a transition in care; patients with uncontrolled

illness (chronic or acute); patients with multiple comorbidities; patients with severe

social-environmental stressors, such as poverty, homelessness, low literacy or

numeracy, high emergency department utilization; or simply those patients who

the PCP or team have designated as in need of additional, intensive care from an

RN in order to progress, stabilize, or avoid regression in their overall plan of care.

The RN engaged in CCM typically provides intensive care management to a subset

of patients, for a time-limited period. In some practices/organizations, the RN may

integrate CCM into total panel support/team-based care, while in other settings,

RNs may be devoted exclusively to complex care management.

Recruiting and training RNs to engage in care at this level is challenging as it

requires a broad-based content knowledge in various chronic illnesses, deep

understanding of pharmacology and medication management, skills such as

motivational interviewing and self-management goal setting, a proactive approach

to using data, and skill in collaborating with other team members. The use of

standing orders is an important part of successful CCM. RNs are able to access

other team members based not just on the PCP's order, but through their own

decision of who may beneﬁt from which services. For example, an RN engaging

a diabetic patient in CCM should be able to access a certiﬁed diabetic educator,

a dietician, and a behavioral health provider on an ongoing or as needed basis to

help with treatment for that patient.

Integrated CCM for patients with comorbid medical/behavioral conditions is rooted

in the idea that, as integral members of the care team, RNs are able to be coach,

gatekeeper, liaison, leader, educator, navigator, and much more. In order for RNs

to achieve successful CCM though, they must not only have electronic health

record access and skills to enter and synthesize the data, but also have access to

actionable data in dashboards and scorecards. The RN ﬁngerprint in primary care

documentation has been vague at best or anecdotal, compared with the structured

and measurable entries made by the PCP and other team members.

There is a growing body of evidence that demonstrates RN care and intervention

makes a difference in acute settings by highlighting the relationship between

increased RN stafﬁng levels and lower rates of certain adverse outcomes,

but

practices that have successfully embraced the role of the primary care RN have

struggled to quantify the impact in a similar way. This has to be a priority in order

to increase the pace at which this national transformation will take place. Data on

impact is key not just to further shape the role of the primary care nurse, but also

to deliver additional tools into the hands of frontline RNs to enhance their ability

to allocate resources based on need (whether in terms of quantity of patients or

complexity of patients) as well as to celebrate overall success.

RN care managers must have robust measures to outline overall performance.

These could include many things, such as the hypertension and diabetes control

rates for the panels they support along with other direct patient outcomes,

transition management timeframes in terms of nursing follow-up contact, as well as

overall tracking of motivational interviewing and self-management goal setting and

follow up.

LEADERSHIP ROLES FOR RNS IN PRIMARY CARE:

A FOCUS ON QUALITY IMPROVEMENT

Quality improvement in primary care has moved from the realm of what must be

done to satisfy regulatory oversight imposed by others, to become a dynamic,

data-driven, and problem-solving approach to improving efﬁciency, care, and

outcomes. Exemplary practices use strategies, such as clinical microsystems, LEAN,

Six Sigma, and others, to identify problems at the micro- or meso-levels, deﬁne

the scope of projects, test interventions, develop playbooks, and implement and

sustain change. However, as with independent nursing visits in primary care, the

entry-level preparation of registered nurses in QI science and methods has not kept

up with the demands of new RN practice roles.

While quality and safety are now required competencies in the American

Association of Colleges of Nursing (AACN) Essentials for Baccalaureate Nursing

Education,

the real question is how well prepared are the pre-licensure and

graduate nursing faculty to teach quality and safety competencies and to model

them in clinical precepting experiences? A recent (2005–2013) RWJF initiative,

Quality and Safety Education in Nursing (QSEN), deﬁned the essential pre-licensure

and graduate nursing competencies for high-quality and safe nursing practice as

patient-centered care, teamwork and collaboration, evidence-based practice, QI,

safety, and informatics.

The QSEN initiative also developed creative teaching tools

and prepared hundreds of faculty around the country to teach these competencies

to undergraduate and graduate students.

While this effort has made a signiﬁcant

impact on preparing new RNs and APRNs, more training in quality improvement

and implementation science methods is needed in continuing education programs.

Otherwise, the primary care practice or organization must provide training and

support to prepare RNs to meaningfully lead population health and QI efforts.

TO TAKE ON THESE NEW ROLES,

WHAT CAN BE RELINQUISHED?

In order to move closer to these emerging RN roles, some traditional RN tasks or

functions must be relinquished or the time devoted to them, reduced. If a task or

function is essential, it may need to be reassigned to non-primary care RNs. Many

practices have done this by increasing the skills and responsibilities of medical

assistants, other lay health workers, and/or licensed practical or vocational nurses

(LPNs or LVNs). Using all team members to work up to their potential allows for

better access, shorter processing time for medication reﬁlls, and increased patient

satisfaction. However making changes to the role of one person on the team

has a deﬁnite impact on all other members of the team, as well as on the team

functioning.

Some of the same strategies that allow RNs to participate more fully in the care of

patients also apply to using other team members to work up to their potential. Two

strategies that we have seen used most effectively are the development of clinical

dashboards for “planned care;” giving medical assistants a set of “just-in-time” data

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to deliver planned care; and ensuring that all a patient’s routine health promotion,

prevention, screening, and chronic illness monitoring needs are met, regardless of

the reason for “today’s” visit. In short, make automatic what can be automatic. In all

but two states, MAs may administer medication, which further frees RNs for nurse

visits and care management. Improved appointment guidelines and training for lay

staff, along with increased appointment capacity, reduces the demand for triage,

freeing up further RN capacity.

Realistically, we note that certain functions, such as triage/telephonic advice are,

in fact, important elements of effective primary care. It is important to separate

“high-value” and “low-value” triage. Low-value triage is a response to inadequate

access/capacity for patients who need to be seen, want to be seen, but can’t be

seen because of inadequate provider capacity; in essence, the role becomes a

frustrating exercise in convincing patients to accept that they can’t have what they

perceive that they need. Low-value triage also results when patients can’t resolve

their concerns on the ﬁrst pass, such as getting a lab result, reﬁlling a medication,

or ﬁnding out the status of a pending or completed referral. Redesigning workﬂow

and capacity is the answer, not investing primary care RN time.

We would deﬁne high-value triage as either dedicated or shared RN time spent

in responding to requests for advice, guidance, and support in determining the

right course of action (home care, ER, primary care visit). Based on the experience

of one large primary care FQHC practice (CHCI) that sees approximately 85,000

patients in a year, the “steady state” demand for RN triage—for those issues that

cannot be resolved by non-licensed staff in a call center—is approximately 80–100

calls per day, which requires approximately two full-time RNs to manage. While

this function could be spread over all the primary care RNs (and has been in the

past), the effectiveness, efﬁciency, and patient satisfaction of dedicated RN triage

staff appears appropriate for large primary care practices. The healthcare industry

has also responded with companies who specialize in providing such services to

primary care practices both during practice hours and after-hours.

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PREPARING RNS FOR THE PRIMARY CARE

SETTING AND EVOLVING ROLES

Preparing RNs to work in primary care settings and to assume these new primary

care roles is a three-pronged education challenge. The ﬁrst challenge is preparing

new RNs by educating today’s RN students and new RN grads for the settings,

competencies, and content of primary care practice. Second is providing staff/

professional development for current primary care RNs to enhance their skills and

take on new and more autonomous roles. Third is providing training and education

to RNs with expertise in the in-patient or other non-primary care settings to

practice effectively in primary care.

Preparing new RNs

First in the education continuum is educating new RNs—students in pre-licensure

programs. The majority of clinical experiences in nursing programs continue to

be in the in-patient care setting, with some limited exposure to public health,

home care, or community health nursing roles. Few pre-licensure nursing

programs provide ambulatory or primary care clinical experiences in their standard

curriculum. Those nursing schools that run nurse-managed centers and/or mobile

vans do provide some primary care and team-based care experiences for RN

students, but this could be expanded.

Nursing educators often cite several reasons for maintaining the in-patient clinical

education focus in pre-licensure programs. For example, the in-patient setting

offers more opportunities for students to quickly master the required technical

nursing skills. Further, achieving the required student-to-preceptor ratio is more

challenging in the ambulatory/primary care setting as space and other constraints

limit the number of students that can be in the clinic/team at any one time. Also the

high-intensity pace of moving many patients through a three-hour session limits

the preceptor’s time with students, and thus the level of students appropriate for

this setting. And, ﬁnally, there is a lack of nursing preceptors who have experience

and feel comfortable teaching in the primary care setting. Unfortunately, then,

most pre-licensure students have no exposure to ambulatory/primary care in their

formative education years and thus little desire or preparation to work in these

settings after graduation.

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Training for the ambulatory/primary care nursing model, and particularly for the new

RN roles, is challenging and requires dedicated time for practical experiences as

the care delivery model is vastly different from the acute setting. Two strategies to

prepare new RNs are nurse residency programs and dedicated clinical experience

in the form of extended clinical rotations or a dedicated education unit (DEU). The

American Association of Ambulatory Care Nurses (AAACN) has advocated for

RN ambulatory residencies to develop RN skills in primary care.

To the best of

our knowledge, however, residency programs in primary care have not yet been

developed for RNs who have completed a bachelor of science in nursing degree.

Such programs could be modeled on the successful post-graduate residency

training programs for new APRNs in FQHCs, which are now well established.

The DEU, which began in acute care, is now being implemented in primary

care at one FQHC with support from a HRSA initiative focused on improving

interprofessional collaborative practice and education.

The DEU concept was

originally developed in Australia at the Flinders University School of Nursing to

address the issue of fragmented and time-limited training for RNs.

In a primary

care DEU, the RN student can experience all facets of the RN role, as well as

experiencing a truly interprofessional collaborative practice environment. No

matter where the RN decides to practice ultimately, he/she would have the tools

to function on a team and to better understand this part of the continuum of care.

A DEU allows for the exchange of hands-on clinical pearls from those currently

delivering the care to those in the next generation. It provides the support and

practice to develop therapeutic language when working with patients, and to

master skills such as motivational interviewing when engaging the patient as

a member of their own care team. This type of experience and support builds

self-conﬁdence, clinical competence, and critical thinking skills to function

independently as an RN in primary care. 

Building nurse residency programs and DEUs requires close partnerships between

nursing education programs and primary care settings. While relationships exist

between hospitals/health systems and nursing programs, they may not extend to

the afﬁliated ambulatory/primary care practices or the independent primary care

sites in the community. Nursing programs would beneﬁt from concerted outreach

to these types of practices to establish clinical teaching relationships beyond

acute care.

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Staff and professional development for new RN roles

The challenge is not only to prepare the next generation of new RNs to practice

in primary care, but also to support primary care RNs who may now be practicing

in a limited role and need to master new skills for new roles. For the RN whose

role in the practice is continually evolving, the level of autonomy and independent

judgement required may be, frankly, frightening and extremely uncomfortable.

When one team member’s role changes, the roles of all members change. This

affects each staff member, not just the core and extended care teams, but also the

patients and the lay staff, such as receptionists.

Many primary care practices have implemented their own formal staff development

programs on-site for RNs and other clinical and lay staff members, while

others have contracted with local community colleges or training programs.

One innovative strategy for both role development and content knowledge

expansion that has been pioneered at CHCI is Project ECHO—RN Complex Care

Management (CCM).

Dr. Sanjeev Arora began Project ECHO at the University of

New Mexico as a telehealth program to support primary care providers treating

hepatitis C, without requiring the patients to travel to the university to see Dr.

Arora and his team. The hope was to improve adherence and treatment support

for patients through building PCP knowledge and self-efﬁcacy in treating their own

hepatitis C patients.

This model quickly grew to include other complex conditions such as HIV,

endocrine, rheumatologic, and many others. CHCI replicated Project ECHO for

hepatitis C and HIV,

but then quickly added chronic pain, pediatric behavioral

health, and even treatment support for providers caring for patients on

buprenorphine. Just as PCPs need additional support to take on complex cases

into their own care, RNs had a similar challenge. Therefore, it was only natural that

Project ECHO then be translated to ﬁt a nursing model to support primary care RNs

as a main focus, instead of the previously provider-centric model.

Once the initial training and competency is completed, ongoing support is critical

since a key component of primary care nursing is the long-term relationship with

the patient and family and maximizing opportunities to motivate and improve

self-management. This is a much harder competency to teach because it involves

developing advanced communication and facilitation skills, along with motivational

interviewing. Through Project ECHO CCM, RNs receive smaller, more manageable

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portions of content with speciﬁc didactic information over time, along with case-

based feedback from expert, multi-disciplinary faculty. This allows for ongoing

hands-on learning, along with a level of support and supervision to ensure the full

integration of new skills.

Re-training RNs to move from in-patient to primary care

For the RN transitioning from the acute care setting, the transition from intensive

responsibility and patient engagement for a few days with a specialized patient

population, to caring for individuals and families over years and encompassing

virtually every health condition, can be overwhelming. RNs coming to primary care

often welcome a “return” to the nursing care they once aspired to: direct, hands on,

highly engaged, family-involved, and holistic, with a focus on restoring health in the

context of family and community. But the transition to a primary care role is a slow

process. The combination of role change and content knowledge requirements

necessitates learning in the practice setting with expert mentors and a planned

curriculum. This takes time, faculty, planning, and ongoing assessment. While this

can be done within the context of formal on-the-job training given appropriate

time and resources (especially for current staff who are expanding their roles), we

strongly advocate for the concept of residency, not just for new RNs but for RNs

who are transitioning from the in-patient to the primary care setting.

Career ladders for RNs in primary care

If we aim to attract and retain the best and brightest RNs to primary care, what

opportunities do we offer them for career advancement? Practices should clearly

identify what the opportunities are for advancement, both at the current level

of education/certiﬁcation and with further education and training, hopefully

supported by robust tuition reimbursement and other policies. Advancement

may be within the practice of nursing or movement into other ﬁelds where such

transitions would not be viewed as a loss. The trajectory from RN to APRN and on

to further advanced degrees is obvious, but so is the potential for advancing within

the primary care practice to greater responsibility or specialization within primary

care, as well as management and leadership. Ideally, the primary care practices of

the future will ﬁnd RNs embedded at every level, from the primary care team to

the c-suite, from the QI department to the business intelligence team, from the

telehealth connection to the homeless shelter or school-based clinic.

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FINANCIAL CONSIDERATIONS

The issue of ﬁnancial reimbursement must be addressed squarely. The

contributions, as well as the cost, of the registered nurse must be identiﬁed,

quantiﬁed, and considered as part of the value proposition. RNs contribute to

the overall revenue generation of a practice as well as its expenses, but they

can also be drivers of RN-speciﬁc revenue generation in fee-for-service systems

through the appropriate billing of nurse visits as allowed under most commercial

insurance plans and some, if not all, Medicaid authorities. Unfortunately, Medicare

recently eliminated the billing of nurse visits using the traditional 99211 code from

FQHC-eligible reimbursement services. In the LEAP project, we found evidence

of involvement of ACOs and insurers in either directly subsidizing the cost of RN

care managers, or contributing to their support through per-member per-month

payments to the practice.

The third category is the still relatively new Medicare payments for non-face-to-face

services, speciﬁcally transition management and care coordination. While not the

exclusive domain of nursing services, it is hard to imagine a primary care practice

being able to capture these payments by delivering these services without the

engagement of nurses. These payments might potentially be expanded to other

payers, particularly Medicaid, if they demonstrate positive impact on cost. Since

January 2015, Medicare has paid separately under the Medicare Physician Fee

Schedule for non-face-to-face care coordination services provided to Medicare

beneﬁciaries with multiple chronic conditions. These payments are available to

FQHC practices as well. Care coordination payment (99490) requires conformity

with a strict set of conditions and tracking, including time (minimum of 20 minutes

of care management services per month of clinical staff time directed by a physician

or other qualiﬁed healthcare professional); patient factors (chronic conditions place

the patient at signiﬁcant risk for death, acute exacerbation/decompensation, or

function decline); and care management services and planning (comprehensive care

plan is implemented and monitored).

Transition management services, clearly intended by Medicare to reduce

readmission to hospital, have been available since January 2013. These codes

(99495, 99496) require follow up communication (telephonic, electronic, or direct)

with patients within two business days of discharge from the acute setting,

medication reconciliation, and a face-to-face visit within 7–14 days with medical

decision making of moderate or high complexity.

Each of these require speciﬁc

106

understanding of the quite stringent rules and requirements for care, service, and

documentation and supervision. Payments are not made in the name of the RN but

rather the supervising provider, but can be easily tracked and attributed to the RN

using the electronic health record and practice management systems.

LOOKING AHEAD TO A “BLUE SKY” FUTURE OF THE

ENHANCED ROLE OF THE RN IN PRIMARY CARE

From the vantage point of 2016, it is remarkable to look back to 2008 and see

the progress that has been made on multiple fronts. We have broadened health

insurance coverage through Medicaid expansion, employer-sponsored plans, and

qualiﬁed health plans. Similar progress has been made in the expansion of team-

based care and PCMH models; the penetration and sophistication of electronic

health records; health information exchanges; and patient portals. Empanelment

and clinical dashboards, embedded quality outcome measures, integration of

behavioral health and primary care, patient engagement and activation, transition

management and complex care management and coordination—all concepts once

considered the province of the avant garde front runners of primary care are now

considered fundamental, if not universal.

What then is the “blue-sky” future of primary care and the role of RNs in taking

us closer to the “promised land,” to paraphrase Barbara Starﬁeld, of better, more

satisfying, and more effective care, close to where people live, work, play, and pray,

in a manner and at a cost acceptable to the individual and the society?

We would

suggest a future in which entry-level preparation of RNs offers the opportunity for

specialization in primary care/community health and public health nursing so that

the essential core knowledge, clinical experiences, and competencies associated

with practicing as part of a collaborative team, in a community setting, with patients

and families over a span of years can be developed. This would also be a future in

which new RNs, or RNs transitioning from other settings, have the opportunity to

elect to do a residency or other training program to better prepare for practice in

this setting.

We envision a future in which every patient has and knows their primary care team,

which includes an RN, a PCP, a medical assistant, and a behaviorist at a minimum,

and that the RN be recognized by the patient and the team as the “go to” team

member for prevention and health promotion activities; minor episodic and routine

107

chronic illness management; and complex care management, in conjunction with

their PCP, behaviorist, and other team members.

We imagine a future in which all RNs are fully trained in population management,

expert practitioners of the clinical microsystems approach to quality improvement,

and can ﬂuidly transition between team leader and team member as the situation

demands. We recognize that telehealth will bring new opportunities and new

challenges for all primary care, and that RNs will engage in teaching, assessing,

counseling, monitoring, and treating patients via remote means.

We imagine a future in which an ‘old’ concept of the public health/community

health RN, knowledgeable about families, neighborhoods, communities, and the

people within them—not today’s “skilled nursing for homebound patients”—might

be updated and re-imagined to reﬂect an extension of the primary care ofﬁce

in which the primary care RN visited the newborn and postpartum mother at

home, saw the recently discharged patients, and provided primary care to aging

populations for whom getting into the primary care ofﬁce is an enormous burden.

This blue-sky state requires much more than just changing educational preparation.

It requires today’s leaders and providers to re-organize today’s primary care

practices and systems to accommodate a truly collaborative model of team-

based primary care. Today’s exemplars must become tomorrow’s status quo.

The Center for Medicare and Medicaid Services’ Transforming Clinical Practice

Initiative, the HRSA-funded National Cooperative Agreement on Clinical Workforce

Development, and other national initiatives offer the opportunity for those in the

ﬁeld today to learn, practice, and transform to tomorrow’s environment. It will

require that nursing leaders and nurses themselves recognize that taking on new

roles and responsibilities means releasing control over domains once considered

the prerogative of nursing, and that lay workers, LPNs, medical assistants, and

health coaches be encouraged to develop new competencies and skills in areas

once reserved to nursing.

We can’t wait for the future to happen; it is here.

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Commissioned Paper

JACK NEEDLEMAN, PhD

UCLA Fielding School of Public Health

EXPANDING THE ROLE OF

REGISTERED NURSES IN

PRIMARY CARE

A BUSINESS CASE ANALYSIS

INTRODUCTION

Primary care is evolving in response to payment reform, new models of work

organization, and changes in the primary care workforce. Advanced practice

registered nurses (APRNs) are part of this evolution, but in this evolving landscape,

the role of registered nurses (RNs) who are not APRNs or nurse practitioners (NPs)

is also being re-examined and re-imagined. There is a growing literature describing

these potential roles and their implementation in healthcare delivery. The issue of

the ﬁnancial viability of employing registered nurses in these new roles, however,

has not been fully addressed. In this paper, I explore the business case and ﬁnancial

issues in this expansion of practice.

I begin by describing the current organization of primary care and the role of RNs

in ambulatory care practices. I then discuss the factors encouraging change in RN

roles, noting especially the growth of the patient-centered medical home (PCMH)

as a model for primary care and the need to support its vision of care coordination

and accountability. This section is then followed by a discussion of the strategies to

support the shifting roles for RNs, describing changes primary care practices have

proposed or implemented. Following this is a general discussion of considerations

in analyzing the business case and ﬁnancial feasibility of engaging RNs in a larger

114

role in primary care. This is followed by a discussion of several settings that have

implemented expanded models, lessons learned in the expansion, and then a

conclusion.

CURRENT STAFFING AND ORGANIZATION

OF PRIMARY CARE

Primary care and ofﬁce-based practice is carried out in a wide range of settings,

including single-specialty practices, multispecialty practices, accountable care

organizations (ACOs), academic medical center and hospital outpatient practices,

and other distinct models (based on the employment relationship of physicians

and revenue model) such as the Veterans Health Administration. In this paper, I

will focus principally on freestanding practices, with some discussion of integrated

delivery systems when considering the business case under capitation.

Ofﬁce-based professional practices make extensive use of a wide variety of

stafﬁng options, including medical assistants, RNs and licensed practice nurses/

licensed vocational nurses (LPNs). In 2011, the Advisory Board Company reported

benchmark stafﬁng data for practices preparing to assume the role of a PCMH,

as compiled by the Medical Group Management Association.

For each physician,

these practices employed on average 1.4 medical assistants, 0.3 LPNs, 0.4 RNs, and

0.1 physician assistants (PAs).

There is wide variability in the use of ofﬁce-based primary care staff (other than

primary care providers, such as physicians, NPs, and PAs) based on variations in

work allocation in practices and number of primary care providers, with some

evidence of economies of scale. A survey by Peikes and colleagues of 496

primary care practices accepted to participate in the Centers for Medicare and

Medicaid Services’ (CMS) Comprehensive Primary Care Initiative found that

nearly all practices employed administrative staff (98.4% on average) and medical

assistants (88.5%), while less than half employed LPNs or RNs (46.6% and 35.9%

respectively).

The proportion of practices employing RNs increased as practice

size increased, from 29.2% in practices with two or fewer full-time equivalent (FTE)

physicians to 88.9% in practices employing more than 13 FTE physicians. Care

managers and coordinators, some of whom might be RNs, were employed in 24.0%

of practices; and pharmacists, social workers, community service coordinators,

health educators, and nutritionists were employed by fewer than 10% of practices,

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although the proportion of practices employing these staff all increased with

practice size, with one-ﬁfth to one-third of large practices employing staff in each of

these categories (other than community service coordinators).

Among practices that employed staff in these categories, there was considerable

variation in the number employed, with the ratio of staff to primary care providers

typically declining as practice size increased, reﬂecting potential economies of

scale. The number of RNs employed varied from 1.04 per physician in the 29% of

practices with 2 FTE physicians or fewer that employed any RNs, to 0.31 RNs in the

largest practices, with an average ratio of RNs to physicians in practices employing

RNs of 0.64. The ratios of RNs to physicians were lower than the ratios for medical

assistants or LPNs across all practice sizes. Other studies report similar staff-to-

physician ratios to those presented by Peikes.

3, 4

The roles played by RNs differ from those played by medical assistants or LPNs.

Registered nurses, with their broad training, extensive education in patient

assessment and clinical care, and licensed scope of practice, have the potential to

play the broadest role. Haas, Hackbarth, and colleagues, in a four-part 1995 series

in Nursing Economic$, analyzed survey data from RNs in different ambulatory care

settings to characterize the roles nurses played in these organizations. While this

study was done in all ambulatory settings, including specialty practices, surgery

centers, cardiac rehab, oncology centers, drug and alcohol treatment centers, it was

among the ﬁrst to identify what nurses were doing beyond the hospital in-patient

setting. The researchers identiﬁed eight dimensions to current clinical practice

roles and three dimensions to their roles in quality improvement and research.

The

roles include enabling operations, such as setting up rooms and taking vital signs;

technical procedures; nursing processes, including developing nursing care plans,

nursing diagnoses, completing histories, and evaluating outcomes; telephone

communication, including triage and calling clients with results; advocacy; teaching;

care coordination; and expert practice within the care setting.

Bielamowicz and Berra report a narrower range of typical activities for RNs and a

clear contrast with the roles played by medical assistants and LPNs. RNs were “tied

up with incoming patient care triage,” while medical assistants and LPNs were used

to room patients and perform basic administrative tasks.

Roles in traditionally organized primary care practices are driven in part by the

cost of different categories of personnel. The compensation analytic website

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salary.com reported that, in February 2016, the average salary for a staff RN in

outpatient care was $65,412, contrasting with LPNs in outpatient care of $43,397

and medical assistants of $32,692. These salary differentials encourage common

tasks in patient rooming and charting, taking vital signs, checking for allergies,

EKGs, stocking supplies and reﬁlling medications, and where allowed by state law,

administration of drugs or vaccines, to devolve in many primary care practices to

medical assistants or LPNs.

Many practices have also sought to expand the role

played by medical assistants in care coordination and monitoring, health coaching,

and panel management.

The effort to minimize costs has encouraged expanding

the role of medical assistants and minimizing the role of RNs to areas such as triage,

where their expertise in patient assessment is distinctively different from medical

assistants and LPNs. As noted in one study, “Many recent recommendations about

collaborative models of clinical care seem problematic when put into a context of

the ﬁndings of current stafﬁng patterns and use of personnel in family practices.

Staff members often fulﬁll roles independent of training.”

There has been growing recognition of the particular strengths of RNs in a variety of

roles in primary care. More recently there have been a number of studies examining

the roles of the RNs—speciﬁcally in primary care practices.

9-13

These more recent

studies identiﬁed additional roles less common two decades ago (transitional care,

LEAN/QI practices, and telehealth) and that speciﬁcally enhance new primary care

delivery models, including intensive care management, medication reconciliation,

direct patient care, and health coaching.

Part of the reconsideration of RN roles has been a greater appreciation of the

distinct competencies of RNs. One primary care system that has experimented

substantially with the health coach role initially hired an RN, LPN, medical assistant,

and psychologist in the initial four health coach positions. Over time, practice sites

in the system have migrated to the use of RNs in these positions.

This is discussed

further in the next section.

FACTORS ENCOURAGING AN

EXPANDED ROLE FOR RNS

While the roles of RNs in primary care have been limited and routine elements

of shepherding patients through a primary care visit have devolved to medical

assistants and LPNs, three factors are encouraging expanding the role of RNs

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in primary care. First, the expansion of payment models beyond fee-for-service

models, such as value-based payment, quality metrics that attribute costs of

hospitalization and other institutional and non-institutional care to primary care

physicians and groups, and expansion of bundled payment and capitation are

changing the expectations for accountability of primary care practices and

increasing the demand for coordination of care, continuity, and more effective

patient management and engagement. Primary care practices are seeking cost-

effective methods to achieve these goals, and looking for alternatives to employing

or placing more demands on the time of primary care providers.

Second, even if primary care practices preferred to expand the engagement of

primary care providers such as physicians, NPs, and PAs in patient care to achieve

the goals of coordination, management, and education, the current and projected

shortage of primary care providers due to lower incomes (relative to specialty

care) and high workloads make this approach unlikely. Those looking to increase

the professional satisfaction and incomes of primary care providers have identiﬁed

increasing the staff support to these providers and shifting some work to other

providers.

12, 15-17

RNs, given the breadth of their education and licensure, have

emerged as a key component in this strategy.

Third, it is increasingly recognized that many of the tasks in coordinating care,

patient education, and engaging and empowering patients in their own care that

are part of the redesign of primary care are areas that draw upon the skills RNs have

in patient care.

One systematic review of nurses in primary care concluded that

while more evidence was needed, “Evidence presented in this review suggests that

nurses in primary care and community settings can provide effective health care

and that they are particularly effective in enhancing patient knowledge and patient

compliance.”

Similarly, a systematic review of general practitioner (GP) delegation

to nurses concluded current evidence “appears to indicate that the delegation of

GP tasks to a nurse in diabetes primary care is at the very least a promising option

with respect to improving patient care.”

STRATEGIES TO ACCOMMODATE INCREASED

ENGAGEMENT OF RNS IN PRIMARY CARE

As the new models of care have been evolving, and in response to primary care

shortages, there has been increased attention to how an expanded role for RNs in

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primary care can be developed and sustained. Much of this work has reimagined

primary care as team-based, with expanded roles for the entire healthcare team.

8-9, 13, 21-27

Speciﬁc examples of alternative models of organization have been

described, including papers by Sinsky and colleagues describing an Iowa primary

care practice,

Reid and colleagues describing the Group Health medical home,

and Anderson and Halley describing Anderson’s implementation of doctor-nurse

team-based system,

a review of 23 high-functioning primary care teams,

and a

discussion of 15 case studies on building teams in primary care.

There are several common features of the vision of expanded team-based care.

There is an expansion of roles for the entire primary healthcare team. Typically, this

is cast in terms of maximizing the contribution of all team members—RNs, medical

assistants, LPNs—to the full extent of their licensure and training, and in some

cases expanding their training. There is also a shifting of some functions from the

primary care provider to other team members, in order to reduce time demands on

the primary care provider or allow team members with greater expertise to assume

speciﬁc functions. In these expanded teams, the number of staff per FTE primary

care provider is increased. This is explicitly discussed by Reid,

Funk and Davis,

and in The Advisory Board Company benchmarking studies.

1, 15

A broad discussion of how the RN role in primary care might be expanded is

presented in “RN Role Reimagined: How Empowering Registered Nurses Can

Improve Primary Care” by Bodenheimer and colleagues of the University of

California, San Francisco Center for Excellence in Primary Care.

They identify

12 strategies for accomplishing this, drawn from the experience of primary care

practices in community health centers, county health systems, and integrated care

delivery organizations:

1. Provide RNs with additional training in primary care skills, so they can make

more clinical decisions.

2. Empower RNs to make more clinical decisions, using standardized

procedures.

3. Reduce the triage burden on RNs to free up time for other responsibilities.

4. Include RNs on care teams, allowing them to focus on their team’s patients.

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5. Implement RN-led new-patient visits to increase patient access to care.

6. Offer patients co-visits in which RNs conduct most of the visit, with

providers joining in at the end.

7. Deploy RNs as “tactical nurses.”

8. Provide patients with RN-led chronic care management visits.

9. Employ RNs’ skills to care-manage patients with complex healthcare needs.

10. Train some RNs to take responsibility for specialized functions.

11. Schedule RNs to perform different roles on different days.

12. Preserve the traditional RN role and focus on training medical assistants

(MAs) and licensed vocational nurses (LVNs) to take on new responsibilities.

Some of these strategies, such as providing additional training, changes in

scheduling, or embedding nurses into teams with deﬁned patient panels, are

instrumental to making more extended use of RNs in care. The other strategies

incorporate three broad approaches to an expanded RN role: ﬁrst, incorporating

RNs into the physician visit more actively to leverage primary care provider time;

second, expanding billable RN-only services; and third, expanding RN activities in

areas not necessarily directly billable.

Increasing the role of RNs in the physician or primary care provider visit to leverage

the time of the provider is reﬂected in the concept of a co-visit. Currently in many

primary care practices, medical assistants room patients, do vital signs, perform

some ordered procedures following the physician examination of the patient, and

may do some charting of the examination. The co-visit substantially expands on

this set of tasks, with the RN taking the lead in taking the patient history and doing

portions of the physical examination and making a provisional assessment of the

patient. After these activities, the physician will join the visit, receive a structured

report from the RN, complete the examination, make or conﬁrm the diagnosis, and

prescribe treatment. In many co-visit models, the nurse will complete the visit by

providing additional information to the patient on the treatment and follow-up and

complete the documentation. The service can be billed under one of the standard

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evaluation and management codes. The primary care provider’s time in direct

contact with the patient is reduced and he or she can complete more billable visits

during the same time period. The more extended time spent with the patient can

also result in a legitimate increase in the time and intensity of the visit justifying

coding the visit as a more intensive visit with a higher payment level.

Typically the need for the patient to see the physician is offset by a clear set of

standing orders or established procedures under which the care is delivered.

Anderson provides a detailed description of the process of care for a co-visit, which

is reproduced in Table 1.

A second strategy for expanding billable services is a nurse-only visit. If this is

done for an established patient, the physician is in the facility, and a standard

procedure has been established, the practice may be able to bill for a nurse-only

visit under billing code 99211. This code is for “Ofﬁce or other outpatient visit for

the evaluation and management of an established patient that may not require

the presence of a physician. Usually, the presenting problem(s) are minimal and 5

minutes are typically spent performing or supervising these services.” Payment is

substantially lower than for other evaluation and management services.

Examples of services that can be billed under code 99211 by RNs include

immunizations; prescription reﬁlls and adjustment of dosages of speciﬁc drugs,

such as insulin based on laboratory or clinical ﬁndings; other diabetes management

activities; and treatment of speciﬁc infections, such as streptococcus or urinary tract

infections in uncomplicated patients. As with co-visits, a protocol embedded in a

standing order is essential for allowing RNs to conduct these services without the

patient seeing a primary care provider. An example of a standing order protocol

for managing hypertension drugs is provided in Table 2. A fuller description of a

standing order protocol is in Appendix A of “RN Role Reimagined.”

There are two other billable options for nurse-only visits incident to physician

services. One is the annual wellness visit that provides personalized prevention plan

services. CMS has deﬁned components for both the initial and subsequent visits,

including obtaining or updating the history, functional status, and risk factors that

are part of a health risk assessment; identifying needed preventive services; and

counseling patients and referring them to appropriate services based on the health

risk assessment.

The current national payment for the initial visit is $173 and for a

subsequent visit is $117.

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Another billable option for nurse-only services in Medicare is chronic care

management services, which allows for 20 minutes per month of clinical staff time

directed by a physician or other qualiﬁed healthcare professional (NP or PA) for

patients with two or more chronic conditions that place the patient at signiﬁcant

risk for death or disability, and for whom a comprehensive care plan has been

established. Payment is $41. The regulation establishing this service permits

clinical staff to provide these services under general supervision rather than direct

supervision of the qualiﬁed healthcare professional.

As suggested above, the creation of standing orders is critical to accommodate

the shifting roles of RNs; for without them, responsibility and decisions remain with

the primary care provider.

State law may govern the creation and use of standing

orders, including requirements for documentation of the approval process;

speciﬁcation of the information to be included in the standing order; speciﬁcation

of the training, experience, and education of the individual who can implement the

standing order and procedures for evaluating their competence; requirements for

notiﬁcation or communication with the primary care provider regarding the patient

condition; and methods for review of the standing orders. The use of standing

orders to permit expanded RN-only visits can substantially change the mix of work

done by RNs in a primary care setting.

The third element of the expansion of RN roles in primary care is increasing RN

engagement in services that may not be directly billable, adding to the FTEs

without obvious fee-for-service (FFS) reimbursement. Examples from the 12

strategies include RN-led new patient visits and RN-led chronic care management

visits not billable under current contracts or rules. While not billable, these services

can increase patient adherence to prescribed care and reduce other healthcare use

and additional spending. They may be particularly important in capitated or shared

savings environments where transitional services and home care can reduce the risk

for hospitalization or readmission. In an environment in which practices are bearing

the risk of additional care because they have accepted capitation or there are value-

based penalties for higher cost patients, the costs of these unreimbursed services

may be recovered through other savings. They can also be revenue enhancing with

bonuses for pay-for-performance and other payment models build on improved

patient outcome which can be very generous.

35, 36

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CONSTRUCTING A BUSINESS CASE FOR AN

EXPANDED ROLE FOR RNS IN PRIMARY CARE

An expanded role for RNs in primary care may require more RN staff. The business

case question is whether the additional costs of stafﬁng can be offset either with

higher revenues or cost reductions in other areas. The answer to these questions

will differ depending on whether the practice is operating under a FFS revenue

model, a capitated model, or other value-based purchasing model. Practices

increasingly operate under multiple models of payment and may tailor services

provided depending on the ﬁnancial incentives. For example, they may offer case

management services to all patients, but aggressively promote these for patients

seen under risk contracts. Similarly, they may focus hospital transition services

intended to reduce readmissions on patients under capitation or shared savings

contracts such as ACO agreements.

Fee-for-Service

In a fee-for-service environment, the cost of increased stafﬁng needs to be

supported by increased volume and higher billings. These could be from an

increase in primary care provider billings from increased productivity through co-

visits; increased visit intensity justifying a higher billing code; or increased billings

from nurse-only visits, wellness visits, or care coordination. For example, it was

noted above that the average salary for an RN in outpatient care was $65,412. If

fringe beneﬁts and related costs are 30%, approximately the level reported on

salary.com, the cost of adding one FTE RN to a practice would be approximately

$85,000. Average Medicare payment in 2013 for billing code 99214, a moderate

(typically 25 minute) evaluation and management visit for an established patient

is $106.83; $72.81 for billing code 99213, a low-intensity, 15-minute visit for an

established patient; and $20.41 for billing code 99211, the code most frequently

used for an RN-only visit. Assuming a 220-day work year (allowing for vacations,

holidays, and some in-service training and related activities), the salary and fringe

would be recovered from a daily average of an additional 3.6 moderate intensity

visits, 5.3 low intensity visits, or 18.9 nurse-only 99211 visits.

The balance of this section discusses speciﬁc strategies used by two large primary

care organizations, including the clinical model used to increase nurse engagement

in care, costs associated with the expansion of nurse stafﬁng, and revenue gains

realized from this expansion in a fee-for-service environment.

123

Clinica Family Health in Lafayette, Colorado

Clinica tested a co-visit model in 2014.

They did this for several reasons: provider

burnout due to heavy use of double booking appointments to meet patient

demand, dissatisfaction of RNs on staff with the bulk of their work being phone

triage, and dissatisfaction with delays in getting patients in for service. They

modiﬁed their primary care provider scheduling to eliminate double booking but

provided for 1-2 co-visits for every two standard visits.

The Clinica Family Health stafﬁng model is built around a medical pod, serving

approximately 3,600 patients. Under its original model, a typical pod had three

FTE primary care providers (MDs, DOs, APRNs, PAs), 1.24 medical assistants/FTE

primary care provider (or approximately 3.7/pod), and 1.0 RNs/pod. In the tested

model, the number of RNs was increased to 3.0 per pod, and medical assistants

were increased slightly to 4 per pod to accommodate the increased number of

visits. Roles within the pod and clinics were also changed. Phone triage was shifted

off the pod, with nurses rotating into triage. Triage declined as more patients were

accommodated on same-day visits. In the pod, one nurse provided traditional RN

services such as wound care, patient education, case management, and monitoring

visits for patients taking warfarin. The other two nurses conducted co-visits. At the

annual national salaries, the cost of this additional stafﬁng would be approximately

$195,000. Per-visit payment averaged approximately $125/visit, from which the

average cost of supplies/visit of approximately $25 should be subtracted. With net

revenue/visit after supplies of $100, the additional stafﬁng costs would be covered

by 1,950 visits.

Table 3 presents the data from Clinica Family Health contrasting its stafﬁng under

the original pod model and the revised stafﬁng to allow for an expansion of co-

visits. Table 4 presents the estimated change in the number of visits, and the

revenue and expenses associated with that expansion. The 6,059 additional visits,

approximately two per day per primary care provider, and approximately six co-

visits per day per nurse, expand visit capacity by 23% and generate a surplus over

expenses, taking labor costs, additional direct costs of supplies, and training into

account. The break-even number of visits is 1.53 additional billed visits per primary

care provider per day, a number that can be accommodated into the visit grid

used by Clinica Family Health under the co-visit expansion model. Clinica Family

Health notes the model and business case analysis only are self-supporting if there

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is sufﬁcient demand for same-day visits that under traditional models are being

triaged to later time periods.

In the article describing the implementation of the program, the authors report

improved employee satisfaction and work/life balance. Patient satisfaction with the

nurse co-visits was higher than the baseline for provider visits.

Mercy Clinics in Des Moines, Iowa

Mercy Clinics, Inc. is a 150-physician, multi-site group practice, with 70% of the

physicians in primary care. It has expanded the use of what it calls “health coaches”

in a variety of ways in pre-visit and inter-visit work. While the initial health coach

model envisioned RNs, LPNs, and medical assistants potentially playing these roles,

as the clinic has gained experienced in using health coaches, almost all health

coaches are now RNs.

The coaches work with primary care providers and patients to provide medical

home and coordination services, review charts and disease directory data in the

clinic to identify patients needing additional care or tests, and identify patients not

meeting clinic-level quality performance goals. They are actively involved in patient

education. The health coach model has been described in a number of publications

by clinic leadership.

14, 36, 37

The coaches play signiﬁcant roles in pre-visit, visit, and post-visit activities. The

pre-visit work is a chart review in preparation for the visit. It identiﬁes the need

for speciﬁc services and follow up that is noted on a worksheet attached to the

chart prior to the visit, and allows for pre-ordering of tests to be conducted during

the visit using standing order sets. Other needed preventive services, such as

mammograms and colonoscopies, can also be ﬂagged in the pre-visit chart review.

Coaches can increase the number of patient visits by doing reminder calls. In

addition to increasing billable services, the pre-visit workup has also assured more

complete care, enabling Mercy Clinics to obtain pay-for-performance payments

based on process-of-care measures such as the proportion of patients receiving

screening.

During visits, as in co-visits, the RN health coach may take patient histories and

perform physical exams. For established patients with chronic conditions, this

includes a discussion of adherence to medications and other treatments. Senior

clinicians at Mercy Clinics commented in interviews that nurses were more effective

125

than physicians in eliciting information on adherence and problems in following

the treatment plans. Coaches also meet with patients after they see their primary

care practitioner to discuss the treatment plan and how it will be implemented. The

nurses and coaches have more time for these discussions than the primary care

practitioners.

Coaches may also follow-up when patients are referred to non-Mercy Clinics

specialists to make appointments, follow up with patient immediately after

appointments, and proactively offer to schedule any recommended imaging or

other follow-up services ordered with Mercy Clinic facilities, retaining the revenue

from those ancillary services.

This set of health coach activities can result in increased visits, increased proportion

of visits at a higher visit level, and increased laboratory and imaging services

as well as preventive services such as vaccinations for ﬂu, shingles, tetanus, and

pneumonia.

Mercy Clinics also uses RNs in nurse-only visits. They have limited the use of 99211

visits in part because of concerns over documenting compliance with the “incident

to” rules but use them for such services as Coumadin clinics to monitor and

adjust doses using standing orders. They have also made extensive use of nurses

in wellness visits, which under the regulations can be delegated to RNs under

standing orders.

Mercy Clinics has not conducted a full business case analysis of health coaches,

but partial analyses have encouraged them to maintain and expand the role in a

fee-for-service environment. Speciﬁcally, they examined the additional billings and

services associated with health coaches in diabetes care. A summary of that analysis

is presented in Table 5. After they introduced the equivalent of 1.6 FTE health

coaches into a primary care clinic with 10 providers, they increased the number of

visits for diabetes-related care, increased the proportion of visits billed at the 99214

level, and increased revenue from laboratory services associated with diabetes

monitoring for Hb1Ac and microalbumin. With just these services considered,

and with the 1.6 FTE health coaches costed at RN salaries and beneﬁts, the clinic

nearly breaks even. When additional services associated with the health coaches

are considered (nurse-only Coumadin clinic visits, estimated at $45,000 in revenue;

increased primary care provider productivity, allowing for more visits per provider,

estimated “conservatively” at $15,000; and identiﬁcation of additional appropriate

126

services for non-diabetic patients), the health coach model almost certainly

generates a net proﬁt for the clinics.

The analysis above does not take into consideration nurse-led annual wellness

visits. Mercy Clinics estimated that nurses can conduct eight wellness visits/day,

but generally schedule six per day, one new visit and ﬁve subsequent visits. Using

national-level nursing salaries plus beneﬁts of $85,000 per nurse and a mix of one

new and subsequent visits for an average national reimbursement rate for wellness

visits of $126 per visit, breakeven to cover salary and beneﬁts would be realized at a

rate of three visits per day, leaving approximately half time for the RN health coach

to carry out other activities, revenue generating or otherwise.

The analysis above does not take into account pay-for-performance bonus

payments from payers for achieving annual process performance standards

along metrics such as the percentage of patients with diabetes receiving HbA1c

screening or eye examinations. These bonus payments can be substantial, making

the business case even stronger. The scope and focus of such programs vary from

payer to payer, but the experience at Mercy Clinics suggests that practices should

examine the bonuses being offered (or penalties being assessed), where they

currently stand on the performance metric and the extent to which they would have

to change to realize the bonus (or avoid a penalty), and the potential for nurse-

staffed efforts to achieve these changes.

Based on their experience, Mercy Clinics is expanding the health coach stafﬁng

from approximately one coach per ﬁve primary care physicians, which was the basis

of the partial business case analysis of diabetes presented above.

Alternative Payment Models

As noted above, we are in a period of changing payment, moving from fee-for-

service to other forms of value payment or shifting risk from payers to providers.

In addition to performance-based bonuses and penalties, there is increased use of

capitation, bundled payment, and shared savings models such as ACOs. Incentives

and business case models considerations under these systems differ from those

under fee-for-service and the costs of additional RNs need to be offset by savings

elsewhere.

One opportunity is to expand primary care capacity at a lower cost than hiring

additional primary care providers. The Clinica Family Clinic experience offers some

127

insight into this. While the co-visit model was developed to ease high workloads

and reduce delays in appointments, it achieved a 23% expansion of visit capacity

and a net positive cash ﬂow for the clinic. The break-even point of an additional

1.53 visits per primary care provider per day represented a 17% expansion of

capacity.

Other opportunities involve offsetting the additional cost of primary care practice

or additional registered nurses with savings in other services. The biggest

opportunities for savings involve reduced hospitalizations and re-hospitalizations,

which can be achieved through more active coordination of care and transition

planning, and reduced emergency department use, which might be achieved

through expanding access for patients at highest risk of emergency department

use. Under capitated systems, there are also opportunities for changes in primary

care practice itself, with greater use of telemedicine, email, phone, and electronic

communication.

One study of the implementation of the Seattle-based Group Health medical home

provides some evidence that the medical home model may achieve these savings.

Reid and colleagues found that, in this model, use of electronic communication

increased and risk-adjusted primary and specialty care costs increased, but

emergency department and urgent care and inpatient costs decreased, for a net

saving of $10.31 per member per month. The Group Health medical home model is

not a direct test of increased stafﬁng with RNs and other ancillary staff. The model

appears to be heavily oriented toward increased use of electronic communication

and strengthening patient-primary care provider links. It does provide a framework

for how the business case for a restructured RN-enhanced primary care practice

could be constructed if data on changes in patient volumes and other outcomes

can clearly be associated with the enhanced role of RNs.

While models for an increased role of RNs in ACOs have been described,

there

has been no overall economic evaluation of these models similar to that done by

Group Health of its enhanced communication models. The efforts by Mercy Clinics

to adapt its health coach model to an ACO environment of shared savings suggests

several partial business case analyses that can guide planning for expanded use of

registered nurses under these types of payment.

Mercy Clinics’s analysis of its cost sharing opportunities suggested substantial gains

if emergency department use could be reduced by 30% and hospital admissions,

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including readmissions, could be reduced by 12%. Its modeling included an

increase in primary care visits of 30%, suggesting a substantial role for making

care available in lieu of emergency departments, and increased care coordination

services. Within this planning framework, Mercy Clinics’ strategy was to segment

its patient population by health risk, with healthy or low-risk patients receiving

appropriate preventive health services and improved access for acute care;

stable, chronically ill patients receiving targeted intensive services; and high-risk,

chronically ill patients intensively managed.

In this system, the role of health coaches would shift. One change was to implement

transition coaches in hospitals to do transition planning for post-hospital care.

Mercy Clinics had hired three FTE coaches for this function for an ACO population

of approximately 60,000 lives. The average cost of an RN with beneﬁts in the Mercy

Clinics region is approximately $60,000 (lower than the national average), so the

cost of the program, with some additional direct costs would be approximately

$200,000. Mercy Clinics estimated that the cost of a readmission was approximately

$10,000. Under a fully capitated system the cost of the program would be

recovered with a reduction of 20 readmissions, and under a 50% shared saving

program, 40 readmissions. The national hospital admission rate for the US in 2010

was 1,139/10,000 population, and if the Mercy Clinics population was hospitalized

at this rate, there would be 6,800 hospital admissions/year for this population. This

rate includes readmissions, which Mercy estimates at approximately 16%, implying

5,900 index admissions and 900 readmissions. Reducing readmissions by 40 would

reduce the readmission rate by less than one percentage point, and Mercy Clinics

believes it can reduce readmissions by three percentage points. A full business case

analysis would also assess the changes in post-hospitalization services required to

prevent readmissions.

A second change in the health coaching model for ACO patients involves coaches

proactively initiating assistance to patients in implementing self-management

services and increased coordination and transitional care services. Mercy Clinics

has, as noted above, segmented its patient population by health status for planning

purposes. Mercy’s average cost per member per month is approximately $400, but

patients with multiple dominant or moderate chronic conditions (approximately

15% of its patients) cost approximately $950 per member per month and patients

with more extensive chronic conditions (approximately 1% of its patients) cost

approximately $2,300 per member per month. Mercy anticipates assigning

approximately 50 high-risk patients to each health coach, although this would

129

not be the sole work of the health coaches working with these patients. If the mix

of these patients matched the overall mix in the ACO, the total projected annual

spending for these 50 patients would be approximately $620,000.

As noted above, the salary and beneﬁts of a health coach at Mercy Clinics is

approximately $60,000. A 10% reduction in health spending on these patients

through more effective care coordination and reduced hospitalization would fully

pay for the coach, not considering other services and savings achieved by the

coaches with other patients, or other value-based bonuses for achieving targets

for patient-reported experience, population-based immunization, screening and

treatment targets, or readmission or admission rates. A 5% reduction would cover

half the cost of the coach.

Fully-integrated business case analysis for capitated or shared savings programs

can be difﬁcult because there are multiple areas of costs and possible savings plus

speciﬁc bonus and pay-for-performance goals that create a complicated planning

environment. The analysis above suggests that organizations can make progress

toward assessing the value of interventions by identifying speciﬁc targets for

improvement (e.g., readmission rates, hospitalization rates, emergency room use),

the magnitude of improvement that can realistically be achieved, the cost return

or revenue associated with those improvements, and based on this, the costs for a

program that would make pursuing those goals appropriate for the organization.

The experience with medical homes and patient-centered primary care suggests

the interventions to achieve improvement involve increased transition planning and

care coordination, areas in which nurses excel. The costs of expanding nursing and

engaging nurses in this work can be estimated and compared with the cost targets

for the programs.

CONCLUSION

Several factors are encouraging efforts to expand the role of RNs in primary care.

The shortage of primary care physicians and APRNs is creating a need to develop

models of care that depend on a more limited pool of these primary care providers.

Efforts to improve the effectiveness of care and increase the extent to which care is

coordinated and integrated through such mechanisms as patient-centered medical

homes are leading to a reorganization of care at the practice level, tapping the

strengths of RNs in patient assessment, communication, and education. Associated

130

with this, tapping the clinical expertise of RNs may address the growing concerns

about increasing the patient centeredness of care and patient engagement as

critical to improving outcomes in such areas as obesity, diabetes, and hypertension

control.

Models for achieving the increased engagement of RNs in primary care, tapping

their expertise, and reducing the demands on primary care providers are being

developed. These include such mechanisms as RN co-visits, nurse-only visits using

standing orders, and increased roles for RNs in care coordination, telemedicine,

patient education, and health coaching.

Because of cost considerations, RN employment in primary care has been limited,

with a focus on triage and supervision of less-trained staff such as LPNs and

medical assistants, and limited utilization of RN skills in assessment, treatment,

and patient engagement and mobilization. The changing model of primary care

and patient-centered care has increased demands for the RN competencies in

assessment, treatment, communication, and patient engagement and education.

Increasing RN involvement in these activities will require increasing the ratio of RNs

to primary care providers from the current average of approximately 0.4 to 1.0. This

will add to the direct cost of these practices, but there are ways to implement these

models that appear to be feasible in business case terms.

In a fee-for-service environment, increased billable services through co-visits and

nurse-only visits can pay for themselves. In a capitated environment, the additional

costs will have to be offset by reduced use of other services, such as emergency

departments and inpatient care. Evaluations underway of patient-centered medical

homes and capitated payment models may shed light on this, but will need to

closely examine the stafﬁng model of the medical home relative to the control

models. Evaluating the feasibility of expanding RN stafﬁng in a value-based or

mixed reimbursement environment will require determining if the time of the RNs

can be focused on those activities that will generate higher volume and revenue

from FFS patients and reduce emergency visits and hospitalizations for other

patients and improved outcomes for all patients. Thus far, business case analysis of

speciﬁc interventions such as those targeted at reduced hospital readmissions or at

reducing admission risk for high-risk individuals with chronic conditions do suggest

that increased engagement of nurses in these speciﬁc programs can repay the costs

as well as improve care.

131

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134

Table 1: Description of primary care provider and clinical assistant (RN)

responsibilities in a routine co-visit

clInIcal assIstant responsIBIlItIes In a routIne vIsIt

The following description of responsibilities relates to routine follow-up visits, such as a routine diabetes check up.

The responsibilities vary for other visit types. For example, physicals include greater emphasis on preventive services,

while responsibilities for follow-up visits for minor illnesses and acute visits are much more abbreviated.

PART I. ASSISTANT ONLY

A. HPI

Welcome patient and conﬁrm patient’s statement of current

problems or symptoms.

Ask appropriate questions for the problems or symptoms,

sing the “ODD IF HAPPY” mnemonic. (Note: The

handbook

provides speciﬁc questions in this format for 116

symptoms and diseases.)

of symptoms – When did this episode start?

D: Description of symptoms – Constant vs.

intermittent, detail of the sensation, character of the

pain, location of the pain, radiation of the pain, etc.

D: Duration – How long does the symptom last?

sity – Is it mild, moderate, severe, etc.?

F: Frequency – Does it occur daily, weekly, etc.?

H: History – Is this the ﬁrst episode, or has it occurred

before?

A: Accompanying signs and symptoms – Do any

other symptoms/signs accompany this symptom?

P: Precipitating/alleviating factors – What makes it

better or worse?

: Progression of the symptom – Is it getting better

or worse?

Y: You have ﬁnished the questions for this symptom.

“plan” from previous two visits.

Review any appended notes or recent phone notes since

previous two visits.

Collect the results of any recently completed diagnostic

tests, lab results or emergency department visits.

problem list and get patient’s update on recent

problems.

Update the problem list with dates of important completed

tests (colonoscopy, mammogram, etc.).

. PAST MEDICAL HISTORY

Review and update medication list, removing completed

medications.

Determine if patient is compliant with medication schedule.

Determine if patient needs reﬁlls.

Ask about side effects from medications.

courage patient to bring all current medications to

each visit.

C. FAMILY HISTORY, SOCIAL HISTORY AND ALLERGIES

Review and update family history and social history.

Review and update allergy list.

D. REVIEW OF SYSTEMS

Review all appropriate systems. (Note: The handbook

can

serve as a guide about which system to review depending

on the problems or symptoms that necessitated the visit.)

E. PR

EVENTIVE CARE UPDATE

Ask brieﬂy about last physical, well-woman exam,

mammogram, lipids, etc.

end and document appropriate preventive care plan.

F. POSSIBLE PROCEDURES AND QUESTIONNAIRES

Administer pulse ox, peak ﬂow, UA, etc., when appropriate.

ister MMSE, Epworth sleepiness scale, Zung scale,

bipolar questionnaire, etc., when necessary.

PART II. ASSISTANT AND PHYSICIAN

Physician enters room, greets patient and, in the presence

of the patient, obtains verbally from the assistant all the

information already gathered.

Physician adds to information as necessary, and assistant

records this additional information.

Physician performs pertinent physical exam and

communicates ﬁndings for documentation by the assistant.

PART III. ASSISTANT AND PHYSICIAN

Physician writes down impressions and plan.

Physician updates problem list if paper charts are used or

communicates to assistant, in writing, problem list changes,

which the assistant records in the electronic medical record.

oblem list must contain information about pertinent

tests and when they are needed.

Physician reviews the impressions and plans with the

patient and then politely exits, leaving the hard copy of the

impressions and plan with the assistant.

PART IV. ASSISTANT ONLY

Document the impressions and plan of the physician.

an includes tests and labs ordered, referrals initiated,

new medications added, medications discontinued,

suggested lifestyle changes, work notes with dates given

and date expected to return to clinic.

Document any treatments or tests refused by the patient,

along with the patient’s acknowledgement of possible

poor outcome.

Provide patient education concerning disease process,

medications, tests ordered or lifestyle changes.

n matters of referral process or obtaining further tests

at other facilities.

Provide all scripts and review them with patient.

medication samples and review dosage schedule.

Remind patient to call if necessary and to schedule any

recommended return visits.

Close the visit kindly or take the patient to appropriate area

of the practice for further in-ofﬁce testing.

Source: Anderson, P. and M. D. Halley. 2008. A new approach to making your

doctor-nurse team more productive. Fam Pract Manag 15(7):35-40.

135

Table 2: Example of protocol for nurse management of hypertension medication

The PCP (primary care provider) completed a visit for a patient with hypertension

(HTN), in which they started a new blood pressure medication, hydro-chlorothiazide

(HCTZ) 12.5 mg once a day, with systolic blood pressure (SBP) target around 140

mm Hg based on the patient proﬁle. The PCP requested that the patient return in

one week for a nursing visit to follow up blood pressure and documented these

follow-up orders in the EMR:

If SBP >180, conduct full HTN screening visit, order metabolic panel

and EKG [electrocardiogram], increase HCTZ to 25 mg daily, and add

benazepril 5 mg daily. Return in one week with PCP.

If SBP between 160 to 179, increase HCTZ to 25 mg daily. Return in one

week with RN and check metabolic panel at that time.

If SBP between 140 to 159, repeat in one week and send results to PCP.

Source: Bodenheimer, T., L. Bauer, J. N. Olayiwola, and S. Syer. 2015. RN Role Reimagined: How

Empowering Registered Nurses Can Improve Primary Care. Oakland, CA: California Health Care

Foundation.

136

Table 3: Adjustments of stafﬁng by Clinica clinics in revised RN stafﬁng model

STAFFING UNDER PRIOR POD STRUCTURE

STAFF CATEGORIES

POD:

3 NIGHT

CLINIC

POD:

2 NIGHT

CLINIC

POD:

1 NIGHT

CLINIC

Medical Provider 3.5-3.9/pod 3.2-3.6/pod 3.0-3.3/pod

Nurse Manager 1.0/pod 1.0/pod 1.0/pod

Clinic Nurse 0.5/pod 0.5/pod 0.5/pod

Float Nurse 1.0/site 1.0/site 1.0/site

Assistant Nursing Director

Medical Assistant Manager 0.5/pod 0.5/pod 0.5/pod

Medical Assistant

1.24/In-Clinic

Provider FTE

1.24/In-Clinic

Provider FTE

1.24/In-Clinic

Provider FTE

Pod Medical Assistant

Float MA 1/Site 1/Site 1/Site

Behavioral Health Provider 1/pod 1/pod 1/pod

Case Manager 1.5/pod 1.5/pod 1.5/pod

Referral Case Manager 0.5/pod 0.5/pod 0.5/pod

Ofﬁce Tech 2.3/pod 2/pod 2/pod

Medical Records 1/pod 1/pod 1/pod

Clinic Operations Technician 2-4 pods/1 COT 2-4 pods/1 COT 2-4 pods/1 COT

1 pod/0.50 COT 1 pod/0.50 COT 1 pod/0.50 COT

BASED ON BASED ON NUMBER OF PODS

Clinic Operations Manager

4 pods/

3 COMS, 3 pods/2

COMS, 2 Pods/1

COM, 1 Pod/0.5

COM

4 pods/3 COMS,

3 pods/2 COMS,

2 Pods/1 COM, 1

Pod/0.5 COM

4 pods/3 COMS,

3 pods/2 COMS,

2 Pods/1 COM, 1

Pod/0.5 COM

Admin Assist 4 pod site/1 AA 4 pod site/1 AA 4 pod site/1 AA

137

STAFFING UNDER REVISED POD STRUCTURE

STAFF CATEGORIES

POD:

3 NIGHT

CLINIC

POD:

2 NIGHT

CLINIC

POD:

1 NIGHT

CLINIC

Medical Provider 3.5-3.9/pod 3.2-3.6/pod 3.0-3.3/pod

Nurse Manager 1.0/pod 1.0/pod 1.0/pod

Clinic Nurse 2.0/pod 2.0/pod 2.0/pod

Float Nurse 1.0/Site 1.0/Site 1.0/Site

Assistant Nursing Director 0.2/pod 0.2/pod 0.2/pod

Medical Assistant Manager 0.5/pod 0.5/pod 0.5/pod

Medical Assistant

1.0/In-Clinic

Provider FTE/Pod

1.0/In-Clinic

Provider FTE/Pod

1.0/In-Clinic

Provider FTE/

Pod

Pod Medical Assistant 1.0/pod 1.0/pod 1.0/pod

Float MA 1/site 1/site 1/site

Behavioral Health Provider 1.0/pod 1.0/pod 1.0/pod

Case Manager 1.5/pod 1.5/pod 1.5/pod

Referral Case Manager 0.5/pod 0.5/pod 0.5/pod

Ofﬁce Tech 2.3/pod 2.0/pod 2.0/pod

Medical Records 1.0/pod 1.0/pod 1.0/pod

Clinic Operations Technician 2-4 pods/1 COT 2-4 pods/1 COT 2-4 pods/1 COT

1 pod/0.50 COT 1 pod/0.50 COT 1 pod/0.50 COT

BASED ON BASED ON NUMBER OF PODS

Clinic Operations Manager

4 pods/3 COMS,

3 pods/2 COMS,

2 Pods/1 COM, 1

Pod/0.5 COM

4 pods/3 COMS,

3 pods/2 COMS,

2 Pods/1 COM, 1

Pod/0.5 COM

4 pods/3 COMS,

3 pods/2 COMS,

2 Pods/1 COM, 1

Pod/0.5 COM

Admin Assist 4 pod site/1 AA 4 pod site/1 AA 4 pod site/1 AA

Notes: Pods are groups of primary care providers (physicians, APRNs and PAs), around which care is

organized. Pods vary in the number of evening shifts per week and therefore base primary care provider

FTEs. Supervisory and management staff not included in table. No changes were reported for these

categories of staff. Categories with changes in stafﬁng bolded.

138

VISITS 26,500 6,059 32,559

STAFFING

FTE Physician 4.94 4.94

FTE NP PA 6.71 6.71

FTE Assist Nursing Director 0.60 0.60

FTE RN 6.12 5.00 11.12

FTE Medical Assistant* 14.55 0.76 15.31

REVENUE

Net Patient Service Revenue $3,648,136 $799,941 $ 4,448,077

Pharmacy Revenue - $ -

ACO, RCCO & Capitated Revenue 206,032 49,199 255,231

Grant Revenue 1,655,811 1,655,811

Contributions 407,825 407,825

Program & Other Revenue 54,704 54,704

TOTAL REVENUE 5,972,509 849,139 6,821,649

EXPENSE

Personnel 2,609,828 417,301 3,027,130

Fringe Beneﬁts 436,243 69,754 505,996

Travel & Training 14,994 2,952 17,945

Medical Supplies 586,301 134,052 720,353

Ofﬁce Supplies 27,097 6,196 33,293

Educational Supplies 331 26 357

Contracts - Patient Care 136,965 10,647 147,612

Patient Related 13,280 3,036 16,316

Employee Related 12,920 2,544 15,463

Administrative Related 2,743 2,743

Building Related 20,284 20,284

TOTAL EXPENSES 3,845,992 646,507 4,492,499

OPERATING INCOME 2,126,517 202,633 2,329,149

Table 4: Estimated initial visits, stafﬁng, revenue, and expenses and change

due to addition of RNs and expansion of co-visits, Clinica

Visits, Stafﬁng, Revenue, and Expenses

INITIAL CHANGE REVISED

Note: Increased visits estimated based on additional visits per FTE physician, NP, and PA per day.

Net increase in medical assistants associated with reduction in stafﬁng per FTE physician, NP,

and PA and increase in ﬂoat MA assigned to pod. Break-even is achieved at 1.53 visits per FTE

physician, NP, and PA per day.

RCCO = Regional Care Collaborative Organization

139

VISITS

Diabetes related visits 881 1,390 509

Percent visits billed at 99214 58% 64% 6%

Average net revenue per visit 78 80 2

STAFFING

FTE Primary Care Providers 10 10

FTE Health Coaches - 1.6

REVENUE

Net Patient Service Revenue 68,454 110,922 42,468

Laboratory Revenue

Microalbumin 22,170 62,119 39,949

HbA1c 37,368 51,145 13,777

TOTAL REVENUE 127,992 224,186 96,194

EXPENSE

Health Coach (assume all RN) 83,950 83,950

Cost of laboratory tests 15,028 28,575 13,547

DIRECT EXPENSES

associated with Health Coaches 15,028 112,526 97,497

OPERATING INCOME 112,963 111,660 (1,303)

Table 5: Visits, stafﬁng, revenue, and expenses associated with care of diabetes

patients before and after implementation of health coach program, re-analysis

of Mercy Clinics data

VISITS,

STAFFING,

REVENUE AND

EXPENSES,

YEAR BEFORE

HEALTH COACH

VISITS, STAFFING,

REVENUE AND

EXPENSES,

TWO-YEAR

AVERAGE AFTER

IMPLEMENTATION

CHANGE

ASSOCIATED

WITH HEALTH

COACH

PROGRAM

Notes: Numbers reported by Mercy Clinics for implementation at one clinic have been modiﬁed in

this analysis by averaging experience in two years post-implementation, shifting stafﬁng to all RN

model, and re-estimating cost of laboratory tests based on volumes reported and Mercy Clinics

estimate of costs.

Mercy Clinics business case analysis also credited program with increase in revenues of

approximately $45,000 from nurse-only 99211 visits, principally for Coumadin clinic, and substantial

pay-for-performance bonuses from private insurers and CMS for achieving quality benchmarks in

diabetes care.

140

141

Commissioned Paper

THOMAS BODENHEIMER, MD, MPH

UCSF Center for Excellence in Primary Care

and

LAURIE BAUER, RN, MSPH

and UCSF School of Nursing

PREPARING NURSING

STUDENTS FOR ENHANCED

ROLES IN PRIMARY CARE

THE CURRENT STATE OF PRE-LICENSURE

AND RN-TO-BSN EDUCATION

INTRODUCTION

Over the past few decades, the costs of health care in the United States have

dramatically increased while the health of populations has declined. Obtaining

desired results and decreasing expenditures necessitates fundamental changes

in how care is delivered.

1, 2

The growth of an aging population, the increase in

number of individuals with chronic health conditions, and the passage of the Patient

Protection and Affordable Care Act

in the US collectively propel the need to shift

the focus of health care from an acute care model to a preventive care model

focused on population health.

4,5,6

With the current emphasis on increasing access

to and utilization of primary care services

and improving satisfaction for both

patients

and primary care clinicians,

9,10

experts across the country are re-imagining

models of primary care delivery. Attention is being drawn to optimizing the roles

of all healthcare professionals on the primary care team, including the role of

registered nurses (RNs).

1,7

Commissioned Paper

DANUTA WOJNAR, PhD, RN, FAAN

Seattle University College of Nursing

and

ELLEN MARIE WHELAN, PhD, RN, FAAN

Center for Medicaid and CHIP Services and Center

for Medicare and Medicaid Innovation

142

Some authors

11,12

have long recognized the unique role RNs play in ambulatory care

settings. Haas and Hackbarth

13,14

proposed new models of nursing care delivery in

ambulatory care based on nursing intensity measures, evidence-based standards

of care, and quality improvement programs. Implementation of these models

resulted in improved patient care outcomes and staff satisfaction. More recently,

the Institute of Medicine (IOM)

identiﬁed RNs as essential players in improving

quality of care and the health of individuals, communities, and populations. Haas

and Swan

speciﬁcally offer that RNs play an essential role as care coordinators

and transition managers in community-based care environments, while Donley

and

Fortier et al.

assert that the role of RNs in a variety of community-based primary

care settings will grow rapidly in the near future, contributing to the quality of care

and improved population health. However, for this paradigm shift in health care

to fully occur, a concerted effort of all stakeholders, including those in nursing

education, must take place. In particular, nurse educators must be forward thinking

and evaluate and revise nursing curricula in order to prepare new generations of

RNs ready to assume expanded roles in the rapidly changing healthcare system of

the 21

century.

LITERATURE REVIEW

At the heart of primary care is the provision of essential healthcare services to

individuals, communities, and populations.

17,18

This set of skills is at the very core

of nursing. Nursing education in the United States emphasizes care of individuals,

families, and communities with a goal to attain, maintain, or restore optimal health

and quality of life, or to assist with the realization of a peaceful death. Originally

trained mainly on-the-job and through religious orders, nurses have been at the

patient’s bedside and in the community, addressing the basic health care needs

of individuals and families. These formal training programs granted diplomas

for nurses, but no academic degrees.

Over the second part of the 20

century,

many graduate nursing programs emerged. In addition, a variety of academic pre-

licensure pathways became available to nursing students (see Table 1). Currently,

learners seeking to obtain their RN licensure within an academic setting may do so

while obtaining their Associate Degree in Nursing (ADN), Bachelor of Science in

Nursing (BSN), Master of Science in Nursing (MSN), or Master of Nursing (MN).

The attainment of a university degree by nurses has long been the preferred entry

to practice.

Students may enter nursing as traditional college students (entering

143

as “freshmen”), as transfer students (“upper division” programs of study), or as

post-baccalaureate learners (students who have a bachelor’s or higher degree

in another discipline and who seek nursing education as a second career). The

IOM

brought renewed attention to the importance of enhancing the education

of nurses and recommended that 80% of RNs become BSN prepared by 2020.

This recommendation resulted in rapid growth of RN-to-BSN programs across the

country.

Applicants to RN-to-BSN programs had their pre-licensure education in

either an associate degree- or diploma-granting institution. Concurrently, with the

rapid shift from acute to ambulatory, community-based, and population-focused

models of care, it is essential that pre-licensure programs prepare students for

expanded roles in these settings.

The American Academy of Ambulatory Care Nursing (AAACN), in particular, asserts

that exposure of nursing students to ambulatory care nursing is essential for proper

preparation of students for practice.

Haas, Swan, and Haynes

identify essential

dimensions of the RN role for ambulatory care and suggest that these dimensions

are easily transferable to other care settings, including primary care. It would seem

reasonable to expect that this preparation of nurses begins while they hone new

knowledge and skills in the pre-licensure nursing programs. However, because pre-

licensure nursing programs have traditionally sought clinical learning experiences

for students in acute, in-patient care settings, it is unclear to what extent they have

shifted focus of student education in recent years. No published research exists

that explores the current state of pre-licensure and RN-to-BSN online education in

the Unites States with regards to the implementation of primary care content. This

study was conducted to ﬁll the gap in knowledge about this important issue for

nursing education and practice.

PURPOSE

The purposes of this study were to (1) explore how nursing education currently

incorporates primary care content in the curriculum; (2) examine curricular changes

that enhance primary care content and clinical opportunities in pre-licensure

(entry) and RN-to-BSN nursing programs; (3) describe challenges to including or

expanding primary care content and clinical opportunities in pre-licensure and

RN-to-BSN online nursing education programs; and (4) offer suggestions for

continuing education needs of RNs to be ready to practice in enhanced RN roles in

primary care.

144

METHODS

Procedure

Institutional Review Board (IRB) approval for protection of human subjects was

obtained from Seattle University (available upon request). The list of Commission

on Collegiate Nursing Education (CCNE) accredited BSN and Master’s entry-to-

practice nursing programs was obtained from the American Association of Colleges

of Nursing (AACN) website. Likewise, a list of the Associate Degree in Nursing

(ADN) Programs approved by the Accreditation Commission for Education in

Nursing (ACEN) was obtained from the ACEN website. Additionally, a sample of the

top 100 online RN-to-BSN programs was identiﬁed via an Internet search. The top

100 RN-to-BSN online programs invited to participate in the study were accredited

by the CCNE and/or ACEN. A nation-wide email survey (Appendix A) was sent

to the selected nursing programs to explore how nursing education currently

addresses primary care content in the curriculum.

Sample

A convenience sample of 1,409 schools/colleges from across the United States

was invited to participate in the survey (677 BSN and/or Master’s entry-to-practice

programs, 632 ADN programs, and the top 100 online RN-to-BSN programs). Of

the 1,409 surveys sent, a total of 529 surveys were returned for an overall response

rate of 37.5%. Most surveys were completed by the BSN and/or Master’s entry level

to practice programs (n=302, response rate=44.6%). Fewer surveys were returned

by the ADN programs (n=179, 28.3%) and the online RN-to-BSN programs (n=48,

48%). A summary of sample characteristics and response rates across programs is

listed in Table 2.

Some of the respondents (n=42, 7.9%) indicated their schools were undergoing

leadership changes and declined to complete the survey. A small number (n=24,

4.5%) of respondents indicated they require an internal IRB and/or curriculum

committee approval to complete the survey. Consequently, only three of these

programs returned completed surveys. One of the schools invited to participate

offers a Bachelor of Arts (BA) in Nursing rather than a Bachelor of Science in

Nursing degree; hence, the school declined to participate. Moreover, some

email contact information found via AACN and ACEN websites turned out to be

undeliverable. Graduate Research Assistants (RAs) conducted Internet searches

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to locate alternative contacts using information posted on the school/college

websites and were able to enlist some participants using this method (n=32, 6.0%).

As appropriate, surveys were completed by the school/college of nursing deans,

directors, associate deans, assistant deans, or other designated personnel.

Method

Summative content analysis was used to analyze survey data.

According to Hsieh

and Shannon, summative content analysis is most useful for analysis of written text

such as manuscript content, journal articles, or survey data; hence, the method was

deemed most appropriate to use in the current study.

Summative content analysis

consists of two levels of analysis: (1) manifest content analysis, which involves

reading and re-reading text to identify and quantify key words and phrases with

the purpose of understanding their usage and context of use; and (2) latent content

analysis, which is the process of summarizing and interpreting content to discover

underlying meanings of the individual words and phrases and the text as a whole.

RESULTS

BSN and Master’s Entry into Practice Programs

Teaching Primary Care Content

Of the 302 (44.6%) respondents in the BSN and MSN/MN entry-to-practice

category, the majority (n=278, 92.0%) indicated they offer traditional, four-year

Bachelor of Science in Nursing (BSN) programs or both the traditional and transfer

program (a two-year program for students with completed non-nursing Bachelor

of Science degree or required science prerequisites before entry to nursing

program). Some respondents (n=22, 7.3%) indicated they have both BSN and

Master’s level entry to practice programs, while two (0.6%) offered Master’s entry

to practice programs exclusively. All the respondents provided general comments

about pre-licensure nursing education in primary care, making it impossible to

discern speciﬁc differences between the BSN and Master’s level entry to practice

programs. The majority of programs in this category (n=247, 81.7%) were

medium-sized (between 200–400 students), fewer (n=44, 14.5%) were large

(over 400 students), and fewest (n=11, 3.64%) were small (less than 200 students).

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Most respondents in the BSN and Master’s entry-to-practice program category (n=

232, 76.8%) indicated they have already implemented at least “some” primary care

content in the curriculum, while admitting they should include more. Like others,

one participant in this group reﬂected:

We have a dean and most faculty understanding the need to shift

student education from acute to primary care. But we still teach primary

care content only to a limited degree. Currently, we address it in two

theory courses (Adult I and Elder Health I) and are only able to expose

students to primary care in Community Health course, and some

peds and OB clinicals. Clearly, we need to be more thoughtful and

methodical about it, but at least we are doing “something” about it.

Respondents from 20 schools/colleges (6.6%) indicated they have implemented

or are in the process of implementing primary care content across the curriculum

in both the theory and clinical courses. Like others in this small group, one study

participant described:

As appropriate, we implemented some primary care content in most

theory courses and, where we could, also in clinical, a couple of years

ago. When primary care clinical is not an option, we teach the concepts

in simulated situations in the clinical performance lab (CPL). We are

lucky to have a strong leadership and faculty willing to entertain the

idea. I believe it is critical we do this if we are to meet the nation’s Triple

Aim goals and as we move from a fee-for-service payment system to a

bundle payment/episodes of care/value versus volume/shared savings

system with a wellness approach instead of a sickness approach. We

are now listed as the most expensive system in the world and ranked

#49 in quality of healthcare delivery. And, we are clearly the most

obese country in the world. If nursing programs don’t prepare the next

generation of nurses to assume the expanded roles in community-

based care settings, nobody will…

Positive Forces Behind Primary Care Content

Of 232 (76.8%) respondents who implemented “some” primary care content in their

curricula, many identiﬁed consistent positive forces that allowed them to move in

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that direction: (1) visionary senior leadership and progressive, “thinking out of box”

faculty (n=128, 42.3%); (2) inviting/collaborative spirit of clinical partners (n=58,

19.2%); (3) current trends in health care (n=33, 10.9%); (4) insufﬁcient number of

acute, in-patient care sites that requires creative alternatives for clinical sites (n=28,

9.2%); (5) growing capacity to provide simulated learning experiences on primary

care in clinical skills, clinical performance, and simulation labs to complement

clinical learning (n=14, 4.6%); (6) synchronization of theory and clinical care content

(n=12, 3.9%); (7) importance of primary care content (n=12, 3.9%); (8) having a

theoretical framework that focuses on health promotion/disease prevention to

guide the curriculum (n=3, 0.9%); (9) mandate from the state nursing commission

(n=3, 0.9%); and (10) a combination of several forces (n=144, 47.6%). Like others who

were successful in implementing some primary care content in their curriculum, one

respondent stated:

The greatest catalysts for implementing the primary care content was

supportive senior leadership, progressive faculty, and changing times.

Ambulatory care sites evolved because we have nurse practitioners

on our faculty who have relationships with these organizations. These

relationships were crucial to allowing the school access to the sites.We

have clinical placement partnerships with the county health department,

a primary care group, and a provider for immigrant care.Some

undergraduate students and all MN students rotate through these sites

for their primary care, others for chronic care rotation. We also have

community-based settings for mental health. For example, we may visit

homeless shelters where clients with chronic mental illness may seek

shelter. It isn’t easy to do and it requires extensive resources, but, as I

see it, it is essential in the 21

century.

Barriers to Primary Care Content

Across participating BSN and MN entry-to-practice programs, the greatest barriers

to implementing primary care content in the curriculum included (1) lack of faculty

buy-in (n=88, 29.1%); (2) too many students in need of primary care placements

and too few available sites (n=74, 24.5%); (3) lack of RN role models in primary

care to serve as preceptors (n=72, 23.8%); (4) student push back/expectation

to receive clinical education exclusively in acute care settings (n=70, 23.1%); (5)

student perception of ‘losing out on skills’ in primary care settings (n=67, 22.1%);

(6) commonly held belief in the community at large that undergraduate programs

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prepare students for work in acute care settings (n=54, 17.8%); and (6) primary care

content not tested on NCLEX-RN licensure exam (n=52, 17.2%).

A number of respondents (n=50, 16.5%) indicated that, beyond a mere

acknowledgement that primary care matters, they had not implemented any

primary care content in their curriculum. Some of the respondents explained

that primary care clinical sites don’t exist in their community or that the sites are

not interested in partnership. Others admitted they intentionally avoid primary

care content in their programs, coming from a philosophical stance that the pre-

licensure programs exist mainly to prepare nurses for work in acute care, in-patient

settings while graduate programs exist to prepare nurses primarily for work in

primary care. Like others in this group, one respondent indicated:

We introduced the concept of primary care in Nursing Fundamentals

and Community courses, but our students have no exposure beyond

that. We plan to keep it this way. There are just a few clinics in our

community and even fewer employ RNs, making it impossible to ﬁnd

the role models for students in these settings. As I see it, the goal

of undergraduate education is to prepare students for work in acute

(in-patient) care and MN students for work in primary care and so we

intend to keep it this way for now.

Another participant stated:

I still think that BSN students should mainly be educated to assume

roles in acute (in-patient) care settings. With the current nursing

shortage, it is more important than ever. I also believe that nurses

should have at least one year acute care working experience prior to

working in any community or primary care center so that they are more

prepared to deal with any emergencies in those environments and/or

so they are familiar with in-patient hospital experiences that follow up at

primary care sites and with community care.

Like others, one respondent summed it up:

We understand this (primary care) is important in the 21

century but

there are many barriers to implementing the content. In our region, my

school competes for clinical sites with other BS programs, AD programs,

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graduate programs, and RN-to-BS programs. This includes access to

primary care and other community-based clinics. Moreover, many of

the sites still don’t employ RNs to serve as preceptors and role models

to students. Scheduling logistics is a nightmare. We lack resources

to efﬁciently schedule students and it falls on faculty; it is very time-

consuming for course coordinators to make the contacts and schedule

students in a myriad of sites given the size of our student population

(main barrier). We do what we can but the picture is far from perfect.

Another participant added:

The biggest barrier in my mind is that faculty feel students will not

learn the skills they need or have enough “clinical experience” to be

competent practitioners. Many faculty, especially adjuncts, do not know

how to “make the most” of these sites; how to build student interest,

build relationships with providers, and create learning situations during

“slow times.” Others worry students may not pass NCLEX without

strong acute care experience. This is why they tend to gravitate to

hospital nursing. Likewise, students feel going to community-based

settings gives them “less than” clinical experience and are pushing

back. I would say, these are the greatest barriers.

Pushback from students also was associated with the lack of endorsement of

community-based education. Similar to others, one respondent shared:

One of the students assigned to a women’s health clinic for her OB/

reproductive care clinical came to me at the beginning of the quarter

very upset about her clinical placement. She works part-time as a nurse

tech in one of the local hospitals. Apparently, she had a conversation

about her clinical with nurses on the unit, and they were bewildered

that we now offer ‘less than’ OB clinical and encouraged the student

to protest. The student was told her clinical placement wouldn’t be

changed and was explained why. She left my ofﬁce disappointed, but it

turned out to be the best clinical learning experience she had.

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Associate Degree (ADN) Programs

Teaching Primary Care Content

Of 632 surveys sent to ADN programs, 179 (28.3%) surveys were returned to the

study. The majority of ADN programs (n=124, 69.2%) were of medium size, some

(n=31, 17.3%) were large, while the fewest programs (n=24, 13.4%) were small.

Consistent with the university-based pre-licensure program respondents, the

majority of respondents in the ADN programs (n=131, 73.1%) indicated they teach

“some” primary care content in their theory and clinical courses.

Positive Forces Behind Primary Care Content

Like others, one respondent summed it up:

We have a ways to go to fully embrace primary care content in our

curriculum. Still, we already teach the content in community health

nursing, pediatric, and mental health theory and clinical. It is a challenge

to rotate large numbers of students through primary and ambulatory

care settings, so shadowing experience is more commonly the case

versus active learning of skills we provide in the acute care settings.

Still, we believe it is important content to teach.

A unique feature of many Associate Degree programs, not mentioned by any of the

university-based program respondents, is that the ADN programs are more likely to

lack access to specialty units in the acute care settings, such as reproductive care

or pediatric units. This was highlighted by 64 (35.7%) of the respondents. Driven by

the necessity and motivation to provide comprehensive learning experiences for

students, many nurse leaders in the ADN programs have long utilized community-

based settings as clinical sites for these specialties. Like others, one respondent

described:

Providing pediatric or OB clinical learning experience at local hospitals

is off limits for my program. Thus, I have to be creative. Our pediatric

theory course, in addition to common pathologies, focuses on healthy

child development. This corresponds quite well with clinical experiences

available to our program, such as the primary and ambulatory care

settings and nurse-run clinics in the school system. It is a great

challenge to rotate and supervise large numbers of students in primary

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and ambulatory care clinics, so observational experience for students

is the most common approach to teaching. Still, they have a great

exposure to what nurses can do. Looking back, what happened out of

necessity now seems to be the preferred location for clinical teaching.

Who would have thought 10 or 15 years ago that we would all be

competing for community-based sites?

Another participant reﬂected:

Preventive care is where nursing is and what nursing is. I think it is

important for students to be exposed to both the acute and primary/

ambulatory care settings since they may ﬁnd jobs in these settings upon

graduation. This is why we are intentional about covering all content,

including primary care in our theory and clinical courses.

Interestingly, according to the ADN program respondents, their students (n=77,

43.0%), in contrast to BSN students’ apparent “push back” against the primary

care clinical experiences, enjoyed clinical placements in primary care settings.

Like others, one participant shared:

I think it is very important they like it and our students seem to like

it a lot. As ADN nurses are increasingly being utilized in out-patient,

community-based specialty care settings, it is important to provide

some experience and knowledge in this area for graduates. The

feedback from our students has been quite positive and many seek

employment in areas outside of the acute care settings after graduation.

Some respondents (n=64, 35.7%) saw lack of access to various specialty in-patient

units and insufﬁcient number of in-patient clinic sites in general (n=38, 21.2%)

as a positive force behind their schools’ seeking community-based specialty

clinical experiences. Still, others saw collaborative attitudes of community-based

clinical partners as a very positive force (n=43, 24.2%). Interestingly, only a few

respondents in this category (n=8, 4.5%) mentioned current trends in health care

and the importance of primary care delivery as driving forces behind primary care

curriculum development.

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Barriers to Primary Care Content

The greatest barriers to teaching specialty clinical courses in primary care settings

identiﬁed by ADN program leaders were (1) the complexity of coordinating clinical

experiences and lack of necessary resources (n=45, 25.1%); (2) difﬁculty with student

supervision (n=22, 12.2%), too few primary care sites available (n=22, 12.2%); and

(3) lack of RN role models in primary care to provide proper precepted experiences

(n=18, 10.0%). Interestingly, none of the respondents in this category mentioned

the community perception that RNs are educated to work in in-patient settings,

but many voiced concerns about the complexity of organizing clinical in primary

care (n=45, 25.1%) and lack of resources in general (n=45, 25.1%). Moreover, some

respondents (n=11, 0.6%) saw the amount of content that must be taught in the

ADN and BSN programs along with the need to adequately prepare students

for success on the NCLEX-RN licensure exam as a difﬁcult barrier to overcome.

Although nearly all ADN program respondents (n=167, 93.2%) agreed that it is

important to expand primary care content to all theory and clinical courses, fewer

saw it as a realistic goal (n=61, 34.0%) because of the lack of resources and the lack

of sites. One ADN Program Director summed it up:

Supervision in a private primary care practitioner ofﬁce is a nightmare

for faculty. You have to let go of how you typically do your work.

Most ofﬁces take only one student, which requires a great deal of

faculty resources and great deal of clinical coordination. Still, I think

it is important for students to be placed in these settings if we are to

decrease the cost of health care and educate nurses to assume new

roles in the 21

century.

RN-to-BSN Online Programs

Teaching Primary Care Content

The third group of programs surveyed was a convenience sample of the highest

ranked online RN-to-BSN programs in the United States (n=100). All of these

programs have some clinical component. Nearly 50% of nurse administrators (n=48,

48%) in this program category responded. Many of the RN-to-BSN program leaders

reported that their programs are large (n=34, 70.8%), and the remaining schools

(n=14, 29.1%) are medium in size. In general, respondents in this category reported

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far fewer facilitators and barriers to implementing primary care content than the

BSN and Master’s entry and the ADN programs.

Positive Forces Behind Primary Care Content

All 48 respondents indicated they have already implemented the concept of

primary care into their theory curriculum and saw it as a positive move toward

an “enhancement of education” for students who received their RN education

in the ADN programs. The majority of respondents (n=31, 64.5%) noted that a

nursing course focused on community health/population health was an important

centerpiece component of their online program because of the direction that

health care is moving. Like others, one respondent explained:

As an educator and a community health educator speciﬁcally, I revised

the curriculum for (our) RN-to-BS completion program to include two

semesters of online classroom experiences in this area (primary care).

I have the highest regard for the signiﬁcance of this content and the

experiences. Consequently, at (our school) we only hire faculty who

share this belief and are enthusiastic to teach it.

Another respondent concluded:

I believe that teaching primary care content is critical to developing

competent nurses who engage in critical thinking and high-level

clinical reasoning. Only this kind of nurse will be able to practice to

the top of their license in community-based settings. We are in the 21

century and we aren’t producing ‘robots’ who simply execute orders

or psychomotor skills, we are producing healthcare leaders for the 21

century. We must always keep this in mind when developing nursing

curricula.

Similar to pre-licensure programs some respondents (n=11, 22.9%) saw visionary

leadership, current trends in healthcare (n=21, 43.75%), and student enjoyment of

learning the content (n=21, 43.75%) as positive forces behind the change.

Barriers to Primary Care Content

In the RN-to-BSN online programs, respondents noted the greatest and only

barrier to exposing the students to primary care clinical experiences was program

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design. Although the content is addressed in the didactic courses, there appears

not to be a designated clinical component except for broadly deﬁned and ﬂexible

“ﬁeld experiences.” Like others (n=25, 52%) who reﬂected on it in the survey, one

respondent explained:

Our community course has a two-credit ﬁeld experience component.

The ﬁeld experience is very ﬂexible. Students may do community

assessment, simulated lab experiences, or a combination of both.

There is no primary care clinical component per se for students in our

program.

A summary of positive forces and barriers to teaching primary care content in the

pre-licensure and online RN-to-BSN programs is displayed in Table 3 and Table 4,

respectively.

DISCUSSION

The expanded role of RNs in primary care, as it is currently unfolding, includes

several key areas of patient care: (1) care management of patients with chronic

conditions; (2) complex care management of high-utilizing, multi-diagnoses

patients; (3) care coordination for patients from hospital to home to primary

care; and (4) RN-led co-visits for patients with uncomplicated conditions, such

as contraception counseling, urinary tract infections, or well mother-baby care

following discharge from hospital. The extent to which primary care is taught in pre-

licensure and RN-to-BSN programs in the United States is evolving, taking multiple

forms of didactic, simulated, and clinical learning experiences, and moving at

variable speeds in response to available resources, institutional policies, and state

regulations (some states mandate teaching primary care in nursing curricula). Also

inﬂuential are the presence of progressive and visionary school leaders and faculty

who recognize the changes in healthcare delivery and patient care needs and have

blazed new trails in primary care education for RNs.

Findings from this study, consistent with Fortier et al.’s

recommendations, suggest

that in order to effectively equip the next generation of nurses “with the skills,

knowledge, and attitudes necessary for the expanded nursing roles in primary care

settings” deliberate actions of dedicated faculty are needed to develop or expand

the primary care content in nursing curricula.

This ﬁnding is also consistent with the

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expert opinion of the AAACN

that pre-licensure nursing programs, in particular,

must shift their focus from an acute in-patient nursing care model to an ambulatory

care nursing care model.

Interestingly, while the vast majority of respondents recognized the need for

curriculum transformation to place greater emphasis on didactic and clinical courses

offering primary/ambulatory care content in pre-licensure and RN-to-BSN online

programs, many consistently identiﬁed obstacles, such as the resistance to change

by faculty, students, and the nursing community at large as well as the unfortunate

lack of appropriate clinical partnerships or sites. These ﬁndings are consistent with

the challenges previously identiﬁed in the literature by Donley

and Yang, Woomer,

and Matthews.

Still, with the projected increase in the number of persons seeking primary care

services as a result of improved access to care granted by the Patient Protection

and Affordable Care Act,

schools and colleges in the US must anticipate a need to

fundamentally redesign their educational models to meet the needs of a greater

number of patients in a systematic fashion. This will require further expansion

of RN-to-BSN programs with a strong focus on community-based nursing

well as professional development opportunities for faculty and staff nurses to

enhance their buy-in and understanding of the enhanced role of the RN in primary/

ambulatory care settings. The professional development opportunities might be

offered at conferences and other meetings, as independent self-study modules,

small group discussions, or webinars. Likewise, team-oriented, interprofessional

clinical education of student nurses may mitigate concerns of job satisfaction and

overwork voiced by healthcare providers currently employed in primary health

care settings.

The current state of primary care delivery models presents an opportunity for

pre-licensure and RN-to-BSN nursing programs to instill in students a spirit of

leadership and collaboration as well as other skills and knowledge essential

to assuming roles of case managers, coordinators of care, and transition care

managers in the re-imagined healthcare system.

New curricula and practice models

will be required from nursing schools and colleges across the nation to prepare

future nurses to function in primary/ambulatory care practice and ultimately serve

as change management and transitional care leaders.

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Findings from this study suggest that a number of nursing schools and colleges

across the country have already implemented some primary care content in

their curricula, particularly in the didactic courses. Fewer programs have also

implemented some primary care clinical courses. Many respondents admitted that

the clinical exposure of students to primary care is often limited by barriers that

often are beyond the programs’ control, such as the lack of primary care sites in the

area or the lack of RN role models at the existing sites. Regardless, some colleges

and schools participating in the study (n=20) have already implemented, or are

in the process of implementing, innovative curricular models with primary care

content at the heart. The following exemplar programs may serve as role models for

nursing programs and other health professions seeking direct experiences in team-

based primary healthcare settings.

Exemplar 1: Seattle University College of Nursing

Seattle University College of Nursing (SU CON) implemented a community/primary

care focused BSN curriculum in spring 2015. Dr. Patricia Benner, based on the work

published by Benner and colleagues

and three faculty taskforces in the CON

(philosophy, content, and program architecture), led the process. Several sources

of input were used to shape curriculum transformation, including in-depth literature

review on the current trends in health care, and feedback from faculty, students,

and community partners.

Consistent with SU’s mission “to educate students to become leaders for a just and

humane world,” faculty embraced Ignatian philosophy to guide the curriculum. As

such, in addition to skills and knowledge that would be expected from students

in any nursing program, carefully cultivated academic-practice partnerships have

led to the creation of clinical experiences for students to work with underserved

populations located outside the in-patient care settings across the curriculum.

Consistent with Ignatian philosophy, students are encouraged to engage in

constant self-reﬂection and to apply the principles of social justice in all clinical

encounters and didactic offerings.

The revised curriculum mandates that faculty embrace a well-balanced approach

to addressing the concepts of common pathologies versus wellness, health

promotion, and disease prevention across the lifespan. This approach encourages

spirited classroom discussions between the students assigned to outpatient versus

acute care in-patient settings, and thoughtful collaboration of mixed teams during

simulated learning experiences in the clinical performance lab. For example, in the

157

population health course, students are required to complete relevant community-

based projects. Additionally, while in all specialty courses across the curriculum,

anywhere from 8 to 16 students are assigned to community-based clinical each

quarter, which allows all students to have meaningful learning experiences in the

community-based settings by graduation.

As previously stated, most community-based sites are located in medically

underserved communities across the Seattle metropolitan area and include primary

care clinics, ambulatory care clinics, school clinics, and public health and homecare

agencies. Students have an opportunity to learn care management of patients

with complex chronic health conditions, such as chronic kidney disease, through

participation in care coordination of such patients from hospital to home, home

visits with the RN, and the subsequent referral to primary care. Others, such as

the students assigned to women’s health clinics, may have an opportunity to learn

various aspects of nurse-managed prenatal care, mother-baby care after discharge

from hospital, and contraception counseling. Moreover, every effort is made to

place students who develop particular interest in primary/ambulatory care nursing

in the appropriate sites for their senior practicum. Because the need for RN skills

set in many community-based agencies is rapidly growing, it is anticipated that

all strong performing students will be hired by these agencies upon successful

completion of BSN program in 2016. Some community-based sites have already

secured funding to offer residency programs for new graduates or are actively

seeking sources of funding.

Exemplar 2: Jefferson College of Nursing at Thomas Jefferson

University

The Jefferson College of Nursing (JCN) at Thomas Jefferson University designed

an innovative, forward-thinking 21

century baccalaureate nursing concept-based

curriculum. This faculty-led initiative is based on Jefferson’s mission,which is

“Health is All We Do,”and JCN’s curriculum, which is described as: “H.E.R.E.–

Humanistic, Evidence-based, Reﬂective, and Excellence in clinical leaders.”

The curricular framework that guides the newly designed concept-based

baccalaureate curriculum is“Promoting Health and Quality of Life Along the Care

Continuum.”This framework emphasizes the promotion of health and quality

of life in a variety of populations during transitions of care from one setting to

another and is guided by the curricular themes of innovation, population health,

interprofessional collaboration, and practice excellence.

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Central to the curriculum is the need to leverage partnerships to support the new

course offerings; immersion experiences (formerly clinical experiences); service

learning; and experiential opportunities in interprofessional, community-based

primary care. These partnerships are mutually beneﬁcial to promote health and

“foster cross-sector collaboration to improve well-being.”

The curriculum for nursing students’ didactic content and immersion experiences

is more closely aligned with the evolving role of RNs beyond the hospital walls.

Students engage in integrated didactic learning and immersion practicums that

promote a culture of health and multiple new and emerging roles of RNs rather than

a disease-based, acute care focused curriculum. Nursing students learn content

related to safe and effective primary care services delivered in community-based

settings, preparing them with knowledge and skills in care coordination; chronic

disease prevention; population health; and team-based, interprofessional care.

Speciﬁc courses address: 1) health promotion across the lifespan; 2) professional

practice; 3) discovery and evidence-based practice; 4) healthcare informatics and

innovation; 5) population health, cultural awareness, and health disparities; 6) care

coordination and care transitions; and 7) clinical reasoning. The curriculum uses

a multidimensional approach that focuses on establishing and expanding upon

academic-practice partnerships with community-based primary care sites, and

assigning dedicated RNs with community-based primary care experience to act as

roles models and preceptors.

Exemplar 3: Western North Carolina School of Nursing

Western North Carolina School of Nursing has partnered with Mountain Area

Health Education Center to offer, as of spring 2016, a highly interactive online

certiﬁcate in Primary Care for BSN-prepared nurses. The certiﬁcate adds value to a

BSN degree by preparing nurses to work at the top of their license in a primary care

setting. The program is designed to broaden students’ perspectives on population

health, to hone care coordination skills across interdisciplinary teams, and to

enhance leadership abilities. There are six courses that prepare students for roles

in primary care: (1) primary care in the 21

century; (2) safety and quality in primary

care; (3) population health; (4) informatics in primary care; (5) role of RN in primary

care; and (6) leader and educator in primary care.

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CONCLUSIONS AND RECOMMENDATIONS

Although results from the current study provide an insight into the existing state

of primary care in pre-licensure and RN-to-BSN online education programs, they

should be used cautiously because the sample was of convenience (N=529), with

the overall response rate of 37.5%, and, thus, may not be representative of all

nursing curricula in the country. Findings indicate that many pre-licensure and RN-

to-BSN programs are undergoing some curricular transformation with increased

awareness of the rapid evolution of the RN role necessitated by healthcare

delivery shifting from inside hospital walls to homecare and community-based

sites. However, the overall magnitude of curricular transformation of nursing

programs to address primary care content is difﬁcult to discern based on the

ﬁndings from the current study. Speciﬁcally, it is difﬁcult if not impossible to make

deﬁnite conclusions whether nursing programs—including those that have recently

undergone or are in the process of undergoing relevant curricular transformation—

address the key RN activities in primary care consistently. Moreover, the extent to

which nursing programs are able to expose students to the full scope of the RN role

in primary care appears to vary greatly depending on site availability and the extent

to which RNs are utilized at these practice sites.

Nursing faculty must be aware of the trends in healthcare delivery and prepare

to respond to the rapidly growing market for nurses in primary care to meet the

healthcare needs of people seeking primary care. Although the majority of the pre-

licensure and RN-to BSN programs participating in this survey have implemented

some primary care content in their didactic and clinical courses, many found it

challenging to thread primary care content throughout the curriculum. Rationalizing

that the sites are insufﬁcient or that only a small percentage of nurses will ever

be needed for work in the primary care, some have demurred from incorporating

primary care learning experiences. It is imperative, however, that nursing schools/

colleges prepare future clinicians for roles in the growing primary care market.

Beyond making curricular changes, efforts will need to focus on changing the

mindset of faculty and students, including prospective students. As care continues

to shift from the acute to outpatient and primary care settings, awareness must

grow regarding the essential roles in chronic illness management, prevention, and

transitional care nurses can assume in these settings. Faculty must increase their

awareness of the current roles of RNs in professional practice and be less reliant

on long-held, untested assumptions that primary care practice is strongest when

160

based on acute care nursing experiences. Nursing programs need to emphasize

accountability for decision making, active participation in team-based care, and

leadership in care coordination to prepare nurses for employment outside of the

acute care setting. Hence, education will need to emphasize physiology, pathology,

and care across the continuum with a speciﬁc focus on leadership.

The primary reason for including theory and clinical content on primary care in

pre-licensure programs is to teach students to holistically consider the needs

of patients and their families and to creatively work with families and other care

providers to meet those needs. Similarly, because many nursing jobs may no

longer be offered in acute care, students need to learn these new skills and be

able to apply them at hire to better meet the healthcare needs of patients seeking

primary care services across the nation. Ensuring students have educational

opportunities to experience nursing practice in settings across the healthcare

continuum, from primary to tertiary care, is essential to their education. Learning

to provide care in primary, community, and ambulatory settings provides new and

exciting opportunities for the development of higher order skills such as enhanced

communication skills, care coordination, problem solving, and interdisciplinary

collaboration across the care continuum.

161

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164

Appendix A

Survey Sent to 1,049 BSN, ADN, and RN-to-BSN Programs

1. In what State is your school located?

2. Which of the statements below best describe your pre-licensure nursing

program(s)?

a) traditional BSN program

b) transfer BSN program

c) Master’s level entry to practice program

What is the size of your pre-licensure program?

a) small (less than 200 students in the pre-licensure program total)

b) medium size (200-400 students total)

c) large (more than 400 students)

Please explain as needed:

3. Which of the statements below best describe your RN-to-BSN program

(if applicable)?

a) online

b) traditional

What is the size of your RN-to-BSN program?

a) small (less than 200 students in the pre-licensure program total)

b) medium size (200-400 students total)

c) large (more than 400 students)

Please explain as needed:

4. Have you implemented primary/ambulatory care content in your theory and

clinical courses in the pre-license nursing curriculum? RN-to-BSN curriculum?

a) Theory: (please describe)

b) Clinical: (please describe)

165

5. If yes, what were the facilitators to implementing the primary and ambulatory

care content in your program? (please describe)

6. What were some important barriers you had to overcome to make it a reality?

7. If you don’t offer the theory and clinical content on primary and ambulatory

care in your curriculum, what are some important reasons? (please describe)

a) theory

b) clinical

8. As a nursing leader in academia, what is your opinion about the importance of

including theory and clinical content on the primary and ambulatory care in the

pre-license and RN-to-BSN nursing programs?

166

Table 1. A Summary of the Pre-Licensure Pathways to Taking the RN License

ASSOCIATE DEGREE IN NURSING (ADN)

Programs are typically offered by community colleges.

Primary pre-requisite courses vary somewhat, but typically include:

• English Composition

• Introductory College Chemistry (100 level) or two semesters of high school

chemistry within the past 10 years

• Introduction to Psychology

• Human Anatomy & Physiology I (must be taken within the last 5 years)

ADN program typically takes two academic years to complete and covers college math,

pathology, pharmacology, psychology, nutrition, human growth and development,

ethics, and a series of nursing didactic and clinical courses that cover common

pathologies and health promotion across the life span.

The ﬁnal course is called ‘senior practicum’ and the length of this clinical experience

varies somewhat.

*Graduates from ADN programs are encouraged to enroll in the RN-to-BSN

program

BACHELOR OF SCIENCE IN NURSING

(BSN) TRADITIONAL PROGRAM

Programs are offered by colleges and universities; students enter the program as

‘freshmen.’

The list of pre-requisite courses varies somewhat:

• Science courses, such as math 1000, chemistry 1200, nursing anatomy

and physiology (two parts, typically with lab), introduction to psychology,

pathophysiology (3000 level), microbiology (2000 and 3000 level), and lower

division elective courses typically taken in freshman and sophomore year

• Nursing theory and clinical courses typically begin in the last quarter/

semester of sophomore year or at the beginning of junior year.

• Material covered includes professional nursing, pharmacology, health

assessment and intervention, promoting care of older adults (theory and

clinical), population health (theory and clinical), promoting mental health

(theory and clinical), promoting reproductive health (theory and clinical),

promoting health of children and families (theory and clinical), promoting

health of adults (theory and clinical), senior synthesis, and transition to

professional nursing course, and senior practicum (clinical), statistics and

research. Leadership and ethics can be offered as stand-alone courses

or concepts threaded throughout the curriculum. Students also are often

required to take some elective courses from other disciplines, such as

philosophy and ethics.

Traditional BSN program typically takes 4 years to complete.

167

BACHELOR OF SCIENCE IN NURSING

(BSN) TRANSFER PROGRAM

Students with completed science prerequisites enter as ‘upper division’ students.

Students with bachelor or higher degree in other ﬁelds and completed science

prerequisites are also admitted.

Coursework typically begins with nursing theory and clinical courses. Material covered

includes professional nursing, pharmacology, health assessment and intervention,

promoting care of older adults (theory and clinical), population health (theory and

clinical), promoting mental health (theory and clinical), promoting reproductive health

(theory and clinical), promoting health of children and families (theory and clinical),

promoting health of adults (theory and clinical), senior synthesis, and transition to

professional nursing course, and senior practicum (clinical), statistics and research. As in

the 4-year nursing program, leadership and ethics are offered as stand-alone courses or

concepts are intentionally threaded throughout the curriculum. Students also are often

required to take some elective courses from other disciplines, such as philosophy and

ethics.

Transfer BSN programs typically take 2 years (typically 7 or 8 quarters)

MASTER OF SCIENCE IN NURSING (MSN OR MN)

Students with completed science prerequisites, extensive volunteer work experience,

and degrees from other ﬁelds are admitted to this intensive, accelerated RN program

Admission is typically very competitive

It typically takes students 5 quarters to complete all pre-licensure courses offered in

the transfer BSN program, and continue on with graduate studies to attain MSN or MN

degree and/or ARNP license in selected specialty over the next 2–3 years.

168

Table 2. Summary of Sample Characteristics

Participating Nursing Programs N=529

Number of Surveys

Sent

Number of Surveys

Returned

BSN & MASTER’S ENTRY

Number 677 302

Response Rate % 44.6%

ADN ENTRY

Number 632 179

Response Rate % 28.3%

RN-TO-BSN ONLINE PROGRAMS

Number 100 48

Response Rate % 48%

TOTAL

Number 1409 529

Response Rate % 37.5%

169

Table 3. Summary of Positive Forces that Encourage Teaching

Primary Care Content in the Pre-Licensure and RN-to-BSN

Online Programs

Participating Nursing Programs N=529

Positive Forces

BSN &

Master’s Entry

(n=302 /

RR 44.6%)

ADN Entry

(n=179 /

RR 28.3%)

RN-to-BSN

Online

(n=48 /

RR 48%)

Combined ‘pressures’ 144 / 47.6% - / - - / -

Visionary leadership 128 / 42.3% 63 / 35.1% 11 / 22.9%

Students like it - / - 77 / 43.0%

21 / 43.7%

Lack of access to in-patient

units

- / - 64 / 35.7% - / -

Collaborative clinical

partners

58 / 19.2% 43 / 24.2% - / -

Trends in healthcare

33 / 10.9% 8 / 4.5% 21 / 43.7%

Insufﬁcient in-patient sites 28 / 9.2% 38 / 21.2% - / -

Increased

CPL capacity 14 / 4.6% - / - - / -

Harmony btw theory/clinical

12 / 3.9%

- / - - / -

Important 12 / 3.9% 8 / 4.5% 31 / 64.5%

Theoretical frameworks 3 / 0.9% - / - - / -

State Mandate 3 / 0.9% - / - - / -

Field experience ﬂexible - / - - / - 32 / 66.6%

Table legend: RR = Response Rate, CPL = Clinical Performance Lab

170

Table 4. Summary of Barriers to Teaching Primary Care Content in

the Pre-Licensure and RN-to-BSN Programs

Participating Nursing Programs N=529

Barriers

BSN &

Master’s Entry

(n=302 /

RR 44.6%)

ADN Entry

(n=179 /

RR 28.3%)

RN-to-BSN

Online

(n=48 /

RR 48%)

Lack of faculty buy-in 88 / 29.1% 35 / 19.5% - / -

Too many students to place 74 / 24.5% 22 / 12.2% - / -

Too few primary care sites 74 / 24.5% 22 / 12.2% - / -

Lack of RN role models 72 / 23.8% 18 / 10.0% - / -

Student pushback 70 / 23.1% - / - - / -

Perception RNs work

in-patient

54 / 17.8% - / - - / -

Complexity coordinating - / - 45 / 25.1% - / -

Lack of resources 54 / 17.8% 45 / 25.1% - / -

Difﬁcult to supervise - / - 22 / 12.2% - / -

Content not tested on

NCLEX

52 / 17.2% 11 / 0.6% - / -

Program design - / - - / - 25 / 52%

Table legend: RR = Response Rate

171

172

173

In this chapter, we have carefully synthesized the thoughtful discussions that

took place during the two-and-a-half-day Macy Foundation conference on

Preparing Registered Nurses for Enhanced Roles in Primary Care. During the

conference, participants were fully engaged in both large plenary discussions

and small breakout conversations that enabled them to jointly draft, consider,

reﬁne, and ultimately agree to a set of recommendations intended to increase

opportunities for registered nurses to help meet the urgent needs of our currently

overwhelmed primary care system. The ﬁnal recommendations are detailed in the

“Conference Conclusions and Recommendations” chapter of this monograph, and

below is a day-by-day overview of how those recommendations were crafted by

the conferees.

During the ﬁrst full day of the conference, participants discussed four Macy-

commissioned papers, which are included in this monograph. The papers,

along with several published articles, all of which participants read prior to the

conference, provided the baseline from which the group discussion was launched.

On the second day, discussions became more focused on identifying the major

themes, challenges, and opportunities on which to base recommendations. At

the close of day two, the conference planning committee worked late into the

night, drafting a preliminary set of recommendations based on the two days of

discussions. The third day, a half day, was devoted to achieving initial consensus

around the draft recommendations, which were then revised, reﬁned, and ﬁnalized

via conference calls and emails in the weeks following the conference.

HIGHLIGHTS FROM THE

CONFERENCE DISCUSSION

174

DAY 1: THURSDAY, JUNE 16, 2016

Opening Remarks and Introductions

The ﬁrst full day of the conference began at 8:00 a.m. on Thursday, June 16,

following a reception and dinner the previous evening, during which conferees

introduced themselves and described their connection to the conference topic. The

44 conferees included leaders in nursing education and primary care from a variety

of settings and playing a variety of roles. Nursing students also were at the table.

Macy Foundation President George Thibault, MD, began his opening remarks

by explaining that the Foundation hosts one major conference each year, and

choosing the topic is a very serious decision. “We look at issues that are ready

for some attention and that would beneﬁt from a consensus statement from a

prestigious group of experts,” he said. He went on to say that the Foundation

chose “enhancing the role of registered nurses in primary care” as this year’s topic

because it represents the intersection of three very important themes.

The ﬁrst theme is the importance of primary care and the need to shift our

healthcare system more fully in that direction to better meet the health needs of

the public in a more effective and ﬁnancially sustainable way. The second theme

is the need to improve nursing education to enhance the status and effectiveness

of nurses as leaders in aligning health professions education with the growing

importance of primary care. An important part of this is promoting the role of

nurses in interprofessional education to teach all health professionals to work

together in teams, particularly in primary care. And third, is the importance

of aligning education reform and delivery reform so that both are moving

collaboratively in the same direction.

Conference Co-Chair Thomas Bodenheimer, MD, MPH, from the University of

California, San Francisco (UCSF) Center for Excellence in Primary Care, then spoke

about the importance of the conference topic for him. During site visits to primary

care practices, Bodenheimer said he saw registered nurses being used ineffectively.

“They were unhappily sitting at computers, doing phone triage all day long,” he

said.

His impression was that RNs performing triage rarely get to see patients face-

to-face, which he believes is a terrible waste of highly skilled professionals.

175

Bodenheimer went on to describe the few examples of primary care practices in

which RNs are “doing really wonderful work, mostly chronic care management,

health coaching, care coordination, and they were much happier than RNs doing

only triage.” He explained that the personal experiences interacting with RNs in

these contrasting situations is what drew him to the Macy conference.

Conference Co-Chair Diana Mason, PhD, RN, FAAN, a professor emerita at Hunter

College Bellevue School of Nursing of the City University of New York, then

provided her thoughts. She spoke ﬁrst about how she, as then president of the

American Academy of Nursing (AAN), was initially connected by colleagues to

Dr. Thibault and the Macy Foundation and they quickly began exploring primary

care nursing as a possible conference topic. “We were all very much interested in

building on the impact of so much important work that had come before,” she

said, including the Institute of Medicine’s report and follow-up work on the The

Future of Nursing.

Mason then spoke about a personal healthcare experience that she ended up

blogging about for the Journal of the American Medical Association. She explained

that, after her husband had surgery that left him temporarily incapacitated and her

as sole family caregiver, they were disappointed with various aspects of care in the

hospital, during the discharge process, and from their primary care practice. She

said that even though they enjoyed access to excellent care, they needed more

information, more clarity, and more care coordination.

“I’m hoping that we come out of this meeting with a strong set of recommendations

that don’t just sit on the shelf,” Mason said. “The Academy [AAN] is going to work

very hard on conference follow up and dissemination, try to increase the impact of

the work, and we’re really interested in your thoughts about how to increase the

impact of this work.”

Following these opening remarks, the conferees began discussing the

commissioned papers, which were presented brieﬂy by their authors and then

discussed by the full group of conferees.

176

Overview and Discussion of Commissioned Paper:

The Future of Primary Care: Enhancing the Registered Nurse Role

Conference Co-Chair Thomas Bodenheimer presented the ﬁrst commissioned

paper, which he co-authored with his UCSF colleague, Laurie Bauer, RN, MSPH. The

paper, The Future of Primary Care: Enhancing the Registered Nurse Role, described

how the transformation of primary care in the United States is creating “favorable

conditions” for growth in the number of RNs in primary care, particularly in larger

practices and community health centers.

These conditions include the current shortage of and professional burnout

among primary care practitioners—physicians, nurse practitioners, and physician

assistants—resulting from increased demand for their services; changing patient

demographics, such as the aging of the population and the increasing prevalence

of chronic conditions; the fact that nurse practitioners, who used to focus more on

chronic care management, are working more and more like physicians, leaving a

need for other providers to perform chronic care management; and the increased

size of primary care practices and the change in primary care ownership from

physician-owned practices to hospital-owned practices, which may make them

more likely to hire RNs.

The authors also elucidated the likely roles of primary care RNs as focused

around patients with chronic disease; patients with complex health needs and

high healthcare costs; and patients whose care must be coordinated across

many settings, including hospitals, skilled nursing facilities, ambulatory practices,

and private homes. Barriers to more RNs working in primary care include scope

of practice limitations imposed by some states and professional organizations;

the scarcity of registered nurses adequately prepared to perform primary care

functions; and payers not reimbursing for work performed by some members of the

primary care team, including RNs.

Following presentation of the paper, Joyce Pulcini, PhD, RN, PNP-BC, FAAN, of

The George Washington University School of Nursing and the Macy Foundation’s

Stephen Schoenbaum MD, MPH, co-moderated a conversation about it. The

discussion initially centered on the need to think broadly about where primary care

is going in the future and how best to align the education of RNs with that future.

“We are in an environment where the change happening is so overwhelming,

but so are the opportunities,” said a conferee. “Healthcare services are moving

177

outside the walls of the clinic or ofﬁce and into the community, into peoples’

homes, and onto the internet. That combined with our need to expand our thinking

and embrace the social determinants of health. This is what our healthcare future

depends on. If we can start with a re-envisioning of primary care very much aligned

with the changing needs of our society, then we have a terriﬁc opportunity to also

re-envision the role of registered nurses in that context.”

Also during this discussion, the need to develop a value proposition around

employing RNs in primary care was ﬁrst raised. “Since quality is such a driving

factor in health care, demonstrating the quality that registered nurses can

provide—making that case regardless of cost—is really important,” said another

conferee. “As our models change, and we know we don’t have a mechanism to pay

nurses for the work that they do from a billing perspective, at least not fully, we

have to think about identifying the quality that RNs can provide. And there is a lot,

but we have to document it better.”

This need to build an evidenced-based argument around the value of RNs in

primary care came up repeatedly during the conference because there are many

who need to be convinced, including payers, other professions, and even nurses

themselves because acute care nursing is more highly valued. In addition to

building cost and quality arguments in favor of primary care nursing, conferees also

mentioned patient experience as a metric that could be improved by integrating

RNs more fully into primary care practice.

One conferee summed it up by saying, “We need to articulate clear talking points

so that we can respond convincingly when someone asks, ‘What do registered

nurses bring to primary care that nobody else does, and why should they be

members of the team?’” Another took it further, reminding conferees that they

should also be thinking in terms of systems change: “When you think about

changing the scope of practice, well then you also have to think about what systems

do we need to impact and how do we effectively impact those systems?”

Another topic touched on during the discussion of the ﬁrst paper was the need

to ﬁnd joy in work. For nurses and other healthcare providers, that often means

building relationships with patients as well as colleagues and teammates. For RNs

who triage all day, they may ﬁnd more joy and satisfaction working directly with

patients and being part of the care team, but their expanded roles and increased

patient interactions may end up impacting the roles of other providers on the team,

178

including medical assistants. The point was made that expanded roles for RNs

should be thought about in terms of the needs of patients and who on the team is

best equipped to meet each of the various needs.

Dr. Schoenbaum wrapped up the discussion of the ﬁrst paper by identifying the

themes that stood out for him. “One of the early themes was focusing on the

opportunities, and it kept coming back in different ways. I interpreted that as

opportunities not just for expanding roles, but also for building better teams.

Another theme was reorienting education so that it’s not so acute-care focused.

And a third big one was that this is ultimately about better patient care.”

He suggested two questions that are very important to answer: what kinds of teams

are needed in primary care? And who might play the major roles that fulﬁll six

core primary care responsibilities to patients, including ﬁrst contact, accessibility,

continuity, comprehensiveness, coordination, and accountability for the whole

person? He also reiterated the need to keep job satisfaction in mind, “because

frankly you cannot get to the Triple Aim unless you have engaged, excited,

proactive people involved in providing the care.”

Overview and Discussion of Commissioned Paper:

Registered Nurses in Primary Care: Strategies that Support

Practice at the Full Scope of the Registered Nurse Licensure

Margaret Flinter, APRN, PhD, FAAN, senior vice president and clinical director for

Community Health Center Inc. (CHCI) presented the next paper on behalf of her

co-authors Mary Blankson, APRN, DNP, chief nursing ofﬁcer for CHCI and Maryjoan

Ladden, APRN, PhD, FAAN, senior program ofﬁcer at the Robert Wood Johnson

Foundation. The paper, Registered Nurses in Primary Care: Strategies that Support

Practice at the Full Scope of the Registered Nurse Licensure, posits that achieving

“better, safer, higher quality care that is satisfying to both patients and providers,

and affordable to individuals and society” will require us to “effectively use every

bit of human capital available in the primary healthcare system,” and presents a

vision for the “blue sky” future of primary care and the role of RNs.

In this future, instructional programs offered by nursing schools, health systems,

professional organizations, and others will help existing RNs transition their careers

to other settings, and will offer learners opportunities to specialize in primary care,

community health, or public health nursing, including the option to complete a

residency or similar clinical education program in community-based settings. Also

179

in this future, in which all patients are served by primary care teams, registered

nurses will take on prevention and health promotion activities, minor episodic

and routine chronic illness management, and complex care management in

conjunction with other team members. They also will possess skills in population

management, quality improvement, and team leadership; will provide counseling

and care services via telehealth; and will expand the reach of primary care into the

community.

In summarizing the paper for conferees, Dr. Flinter outlined ﬁve overarching

themes.

1. The need to ensure that RNs in primary care are practicing to the full scope

of their licensure because “they are key to our ability to meet the demand

for care.”

2. The need for leadership around changes in primary care practices that

would allow for the creation of a pathway—such as the use of standing

orders and dedicated order sets—that enables RNs to engage with patients

around medical regimens, such as adjusting medication dosages.

3. The need to recognize the critical role primary care RNs can play in

complex care management.

4. The need to consider the roles of nurses in relation to other members of the

interprofessional team and not in isolation.

5. The need to improve nursing education and training by, for example,

adapting the concept of the dedicated education unit for primary care.

This would give undergraduate nursing students practical primary care

experiences such as conducting independent nurse visits, managing

complex care, and being part of a team.

The conversation around this paper began with conferees being asked by the

moderator, Debra Barksdale, PhD, FNP-BC, CNE, FAANP, FAAN, of Virginia

Commonwealth University, to, among other things, describe what the “blue sky”

future of nursing might look like as well as the barriers to achieving it. A conferee

responded by stressing the need to, in partnership with patients, reframe primary

care around the concepts of prevention and patient-centeredness because “we are

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not delivering on that.” She held up international examples of primary care nursing,

in which registered nurses serve as the primary point of contact with families and

community members.

The international theme was picked up by another conferee, explaining that she

currently is studying New Zealand’s approach to workforce planning, which involves

assessing care pathways. “They take, for example, diabetic patients and ﬁgure out

workforce needs from the patients’ care pathways, from home perhaps into primary

care to acute care,” she said. “They don’t ask ‘how many nurses do we need?’ They

ask, ‘What are the patients’ needs for care in each of those places and how can we

redesign the workforce to meet those needs along a care pathway?’” The conferee

went on to explain that this approach could be used to plan the “blue sky” future of

primary care nursing in the United States.

The conversation was then expanded to include the need to identify factors that

could help drive the changes being discussed. “What are the leverage points?” a

conferee asked. “Where and who is this change going to come from? We see in

these commissioned papers a variety of leverage points already mentioned—the

shortage of primary care providers; the shift to team-based care and being held

accountable for population health; the shift to larger, hospital-owned practices, etc.

But I think we ought to be thinking about adding to the list. And fundamental in

this is whether we push speciﬁcally for an increased role for RNs or push to improve

primary care and let the role of the RN evolve accordingly.”

Isolation among primary care nurses was the ﬁrst of the barriers raised by a

conferee, who said, “I come from an acute-care setting attached to an ambulatory

care setting, and we see a lot of turnover among our primary care nurses because

they feel alone and disconnected; there’s no strong culture of nursing in primary

care. So it’s not just about how do we get them into these new roles, but how do

we create primary care environments where they want to stay, where they can

thrive?” She mentioned the American Nurses Credentialing Center’s Magnet

recognition model as an example of a way to create a supportive environment for

nurses within a primary care organization.

Another barrier raised was payment, which came up repeatedly throughout the

conference. In this instance, a conferee expressed concerns about the conversation

so far setting up impractical paradoxes. He noted that conferees were, on one

hand, discussing the need to hire RNs to add primary care capacity without a

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clear mechanism for receiving reimbursement for their work, while on the other

hand, also discussing bringing in RNs not only to help reduce the workload, but to

actually have them take on new roles and provide new services, also without a clear

reimbursement mechanism. “I just think we need to be realistic and think about

what’s feasible,” he said.

In response, a conferee who said his community health center has a 1 to 1.2 ratio

of doctors to registered nurses, explained that the shifts being discussed—toward

team-based population health, toward social determinants of health, toward care

management and coordination, toward RNs in primary care, toward community

engagement—have already happened. “We’ve already waded in there,” he said.

“We’re in it. And, just like in this room, we still have a lot of questions, but we’re

ﬁguring it out. It’s working. We need more RNs. We have grants now helping with

the payment issues, but I think we’ll ﬁnd answers to the cost issues around caring

for the most expensive patients and changing the payment models.”

Overview and Discussion of Commissioned Paper:

Expanding the Role of Registered Nurses in Primary Care:

A Business Case Analysis

The third paper discussed at the conference, Expanding the Role of Registered

Nurses in Primary Care: A Business Case Analysis, was written and presented by

Jack Needleman, PhD, FAAN, professor and chair of the department of health

policy and management at the University of California, Los Angeles Fielding School

of Public Health. The paper describes new roles for RNs that achieve economic

gains by engaging their expertise and reducing demands on primary care

clinicians. These roles include RN co-visits; RN-only visits using standing orders;

and increased responsibilities for RNs in care coordination, telehealth, patient

education, and health coaching.

Through two case studies, Dr. Needleman describes how primary care practices

have ﬁnancially supported the expanded role of the RN. For example, in fee-for-

service settings, increases in billable services can help pay for RNs in these new

roles, while in capitated settings, additional RN-related costs can be offset by

reduced use of other services, such as emergency department visits and hospital

readmissions. The author calls for additional research to examine the feasibility

of these roles under emerging value-based payment structures and solidify the

business case, but also explains that the evidence suggests increased engagement

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of RNs in caring for high-cost patients with chronic conditions will pay for itself and

improve care.

The discussion around this paper was co-moderated by Bobbie Berkowitz, PhD, RN,

FAAN, of Columbia University School of Nursing, and Ellen-Marie Whelan, PhD, RN,

CRNP, FAAN, of the Center for Medicare and Medicaid Innovation at the Centers

for Medicare and Medicaid Services (CMS).

Dr. Whelan opened the discussion: “There are several things happening that are

helping us to look at this question of return on investment (ROI),” she said. “The

ﬁrst is the movement away from fee-for-service, and I might be more optimistic than

most. I’m at CMS, and we’re working on trying to move away from fee-for-service,

and in that new payment model, there are some huge opportunities. We are paying

for patient outcomes now (or hoping to), not the services that are being delivered.

“Also, there are the social determinants of health,” she said. “We’re moving in that

direction. Medicaid, for example, pays for housing services and care delivered in

schools. And there’s the question of where will care be delivered? Not necessarily in

clinics anymore. Eight-ﬁve percent of our healthcare dollar is spent on people with

chronic conditions and most of what keeps them healthy is at home or at schools or

in their workplaces—places that nurses are very comfortable.”

A few conferees pushed back on the tensions and assumptions raised in Dr.

Needleman’s paper—concerned about how hard it is to measure ROI around

provider competencies and patient outcomes and that efforts to do so have been

around for decades.

A conferee summed up her federally qualiﬁed health center’s (FQHC’s) experiences

with primary care nursing. “We continue to struggle to justify the cost of RNs

in an FQHC with a ﬁscally constrained budget,” she said, “but we have, as an

organization, continued to prepare our nurses and believe in our nurses’ ability

to share care on our care teams. With co-visits, for example, when patients see a

physician or other practitioner in addition to an RN, the value of that co-visit for

a patient is 15 or 20 minutes of face-to-face time with a care team member. They

got seen the day they wanted to be seen, which was today. And we’ve measured a

bunch of this around nurse tasks, volume of work.”

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Other conferees spoke about successful examples of RNs providing care in their

own practices, including those with fee-for-service payment models. “The payment

structure is something that must be ﬁgured out, but let us innovate around it and

it will get ﬁgured out. It is already being ﬁgured out,” said one conferee. While

another, a physician, spoke about registered nurses leading his practice. “There

are three of them, and one of me,” he said. “That’s a ratio that really works for

us. They are in charge. They keep things running smoothly and pull me in when

needed. There’s no triaging; they don’t spend their time on the phone in front of a

computer. They’re making decisions. They’re consulting with and supporting each

other. They have relationships with patients and often know the patients better than

I do.”

Another commenter wrapped up this discussion saying, “These handful of bright

spots being discussed—these examples of primary care clinics that have hired more

RNs, that have changed their role, and are succeeding in ﬁnancing it—learning

from these bright spots is where the business case for RNs in primary care starts.”

(Proﬁles of these exemplar primary care practices are included in this conference

monograph.)

Overview and Discussion of Commissioned Paper:

Preparing Nursing Students for Enhanced Roles in Primary Care:

The Current State of Pre-Licensure and RN-to-BSN Education

The ﬁnal commissioned paper discussed at the conference was Preparing Nursing

Students for Enhanced Roles in Primary Care: The Current State of Pre-Licensure

and RN-to-BSN Education. Presented by authors Danuta Wojnar, PhD, RN, FAAN,

of Seattle University College of Nursing, and CMS’ Ellen-Marie Whelan, the paper

offered results from a survey examining primary care content in the curricula of

the more than 500 pre-licensure (entry-level associate, baccalaureate, or master’s