Cultivating the Role of Nurse Practitioners in Providing Primary Care to Vulnerable Populations in an Era of Health-Care Reform

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1 Article Cultivating the Role of Nurse Practitioners in Providing Primary Care to Vulnerable Populations in an Era of Health-Care Reform Policy, Politics, & Nursing Practice 2016, Vol. 17(1) 24 31! The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: / ppn.sagepub.com Ying Xue, DNSc, RN 1 and Orna Intrator, PhD 2,3 Abstract The evolving role of nurse practitioners (NPs) as primary care providers, especially for vulnerable populations, is central to the debate regarding strategies to address the growing need for primary care services. The current article provides policy recommendations for leveraging and expanding the historic role of NPs in caring for vulnerable populations, by focusing on three key policy levers: NP scope-of-practice regulation, distribution of the NP workforce, and NP education. These policy levers must go hand in hand to build a sufficient and equitably distributed NP workforce, to help meet the escalating need for primary care in an era of health-care reform. Keywords nurse practitioners, primary care, vulnerable populations Intersecting trends characterized by an aging population, persistent and widening health inequalities, an expansion of access to primary care under health-care reform, and impending shortages of primary care physicians have challenged the ability of the U.S. health-care system to meet the growing demand for primary care services, especially among vulnerable populations. Nurse practitioners (NPs) have a long and storied history of providing care for rural and vulnerable populations. The NP workforce is growing, and the practice authority of NPs has been expanding over the past few decades. The role of NPs in providing primary care, especially for vulnerable populations, is therefore central to deliberations regarding strategies to meet the growing demand for primary care under health-care reform. Legislative, workforce, and educational policies should be addressed in concert to ensure an adequate supply and equitable distribution of NPs in primary care delivery for underserved and vulnerable populations. In this article, we begin with a discussion of vulnerable populations and then examine the evolving role of NPs in delivering primary care to these populations. We outline three key areas in which policies could intervene to help foster and advance the role of NPs in serving vulnerable populations and conclude with the role of NPs in policy advocacy. Our goal is to provide policy recommendations for national and state policy makers to leverage and expand the historic role of NPs in caring for vulnerable populations. Vulnerable Populations Vulnerable populations have been defined as groups deemed to be most susceptible to adverse outcomes due to limited resources or neglect, and include people who were poor, uninsured, homeless, elderly and frail, and suffering from a range of chronic diseases, or special populations in need such as Native Americans and low-income veterans (Mechanic & Tanner, 2007, p. 1220). Nationally, vulnerable populations account for a disproportionate burden of disease and excess death Medicare data shows the prevalence of 1 University of Rochester School of Nursing, Rochester, NY, USA 2 Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA 3 Canandaigua VA Medical Center, Canandaigua, NY, USA Corresponding Author: Ying Xue, University of Rochester School of Nursing, 601 Elmwood Avenue Box SON, Rochester, NY 14642, USA. ying_xue@urmc.rochester.edu

2 Xue and Intrator 25 chronic illness among dual beneficiaries (individuals receiving Medicaid and Medicare) is higher than in non-dual Medicare beneficiaries. For example, the prevalence of depression or Alzheimer s disease is twice as high among dual beneficiaries than non-dual beneficiaries and more than 70% higher for diabetes (Center for Medicare & Medicaid Services, 2012). Low-income populations account for the majority of nursing home residents (Harrington, Carrillo, & Garfield, 2015). Between 1999 and 2010, racial and ethnic minorities in the United States accounted for 12.7 million more years of life lost due to excess deaths than non-hispanic Whites (Howard, Peace, & Howard, 2014). Such health inequalities have been associated with enormous economic costs, resulting in $229 billion in direct medical care expenditures and $1.24 trillion in lost productivity from 2003 to 2006 (LaVeist, Gaskin, & Richard, 2011). Hence, eliminating or reducing health inequalities thus represents a major public health research and policy priority (U.S. Department of Health and Human Services, 2010). Yet, health inequalities are expected to increase as the U.S. population becomes increasingly racially and ethnically diverse (Hobbs & Stoops, 2009) and as both the number of people living in poverty and household income inequality increase (Bishaw & Semega, 2008). It is important to recognize that health inequalities are deeply rooted in socioeconomic disadvantage, defined as unfavorable social, economic, or political conditions that some groups of people systematically experience based on their relative position in social hierarchies (Braveman et al., 2011, p. S151). Poor socioeconomic conditions such as poverty, underemployment, homelessness, discrimination, and structural violence limit access to safe environments, healthy food and lifestyles, and health-care resources. Limited access to health care by vulnerable populations cannot be viewed in isolation but must be considered within a broader socioeconomic context and policy response that reaches beyond the individual patient, to families, communities, and the larger society. Such an approach is needed to address the fact that vulnerable population groups tend to reside in areas designated as primary care Health Professional Shortage Areas (HPSA; Huang & Finegold, 2013; Ku, Jones, Shin, Bruen, & Hayes, 2011) and that lower primary care capacity is found in states with the highest rates of uninsured residents (Ku et al., 2011). Persistent inequalities in health-care access have led to a disproportionate burden of disease and mortality among vulnerable populations (U.S. Center for Diseases Control and Prevention, 2011). The Role of NPs in Primary Care Delivery for Vulnerable Populations Historically, NPs have played an essential role in the delivery of primary care to vulnerable populations (Morgan, Everett, & Hing, 2015). The NP role emerged in the 1960s in large part to address the projected physician shortage in providing care for vulnerable children (Donelan, DesRoches, Dittus, & Buerhaus, 2013; Van Zandt, Sloand, & Wilkins, 2008). Currently, NPs are key providers in safety-net primary care settings that serve as the main source of primary care for more than 23 million minority and low-income patients, including nearly 1,300 community health centers and over 250 nurse-managed health clinics (Hansen-Turton, Bailey, Torres, & Ritter, 2010; National Association of Community Health Centers, 2014). They are increasingly becoming an important part of the nursing home workforce with over 35% of nursing homes employing NPs by 2010 (Intrator et al., 2015). NPs have contributed substantially to the health of vulnerable populations through a unique approach to care delivery. Extensive evidence shows that in addition to providing a broad range of primary care services at a level of quality similar to physicians, NPs typically provide a greater level of care coordination and have higher patient satisfaction ratings (Morgan et al., 2015). NPs take a holistic approach to care of vulnerable populations that emphasizes community health, prevention, and social well-being (Henry, 2015). Research indicates that NPs provide care to more socially complex patients who are otherwise less medically complex (Dahrouge et al., 2014). NPs are therefore uniquely qualified to address the broader socioeconomic context within which primary care is delivered to vulnerable population groups. Recent health-care reform policies and initiatives under the Affordable Care Act (ACA), such as expanded insurance coverage and $11 billion investment in community health centers (Health Resources and Services Administration, 2015), have created increased demands for NPs to fill the growing need for primary care among vulnerable populations, thereby addressing persistent health inequalities. The role of NPs providing primary care for low-income, minority, and other vulnerable populations has been expanding with these initiatives. Community health centers are twice as likely to use NPs, physician assistants (PAs), or certified nurse midwives than other primary care settings (National Association of Community Health Centers, 2013). The number of NPs employed in relation to the number of physicians has steadily increased in federally qualified health centers, which operate about 9,000 health service delivery sites in the United States, and the demand for more NPs is expected to continue (Health Resources and Services Administration, 2015; National Association of Community Health Centers, 2013). Evidence has suggested that future growth in these safety-net primary care settings could play a substantial role in addressing primary care provider shortages (Auerbach et al., 2013).

3 26 Policy, Politics, & Nursing Practice 17(1) However, community health centers or rural health clinics have persistent challenges in recruiting and retaining primary care providers (Rieselbach, Crouse, & Frohna, 2010; Wright, Damiano, & Bentler, 2015). For example, a recent survey of 142 rural health clinics indicated that 80% had difficulty recruiting physicians and 50% had difficulty recruiting NPs and PAs (Wright et al., 2015). As the national primary care NP workforce is projected to increase 30% by 2020 (Auerbach, 2012; Health Resources and Services Administration & National Center for Health Workforce Analysis, 2013), it is imperative to cultivate the role of NPs in providing primary care to vulnerable populations to improve access to care and reduce health inequalities. Concerted Policies Needed to Cultivate the Role of NPs in Serving Vulnerable Populations NP Scope-of-Practice Regulations NP scope-of-practice (SOP) is governed by individual state nurse practice act. SOP varies from state to state ranging from full-authority autonomous practice to restricted physician-oversight practice. As of 2015, 21 states and the District of Columbia have adopted full autonomy practice legislation for NPs, authorizing NPs to evaluate patients, order and interpret diagnostic tests, and manage treatment, including prescribing of medications (American Association of Nurse Practitioners, 2015). This reflects a growing trend among states to liberalize NP SOP regulations. From 2001 to 2010, eight states removed requirements for physician involvement in diagnosis and treatment, two lowered the level of physician involvement from supervision to collaboration, and 10 states increased the prescriptive authority of NPs (Gadbois, Miller, Tyler, & Intrator, 2015). Yet, as of 2015, 29 states had laws that either reduce or restrict NP SOP, limiting autonomous practice and requiring physician collaboration or supervision. The expansion of state laws authorizing autonomous NP SOP is critical for NPs to meet the increasing demand for primary care by delivering care to the fullest extent of their education. More autonomous SOP regulation could promote the use of NPs in primary care delivery in rural and medically underserved areas. Provider-based rural health clinics, which were designed to increase the use of NPs and PAs to improve access to primary care in rural areas, were 30% more likely to be established by rural hospitals in states granting prescriptive authority to NPs than in those without this authority (Krein, 1999). In addition, community health centers were shown to have more flexibility in staffing choice (Ku, Frogner, Steinmetz, & Pittman, 2015) and were more likely to increase the use of NPs in states with more autonomous practice environments (Ku et al., 2015; Shi & Samuels, 1997). SOP regulation was also one of the most important factors in determining staff composition in federally qualified community health centers located in areas with a short supply of primary care physicians (Ku et al., 2015). Given the high disease burden and concomitant health-care costs characteristic of vulnerable populations and the expanded access provisions of the ACA, SOP legislation represents one of the most critical regulatory issues faced by states in providing adequate and affordable care to their residents (VanBeuge & Walker, 2014). State NP SOP regulation affects not only the SOP but also the number, availability, and distribution of NPs (Kaplan, Skillman, Fordyce, McMenamin, & Doescher, 2012; Kuo, Loresto, Rounds, & Goodwin, 2013; Reagan & Salsberry, 2013). A recent systematic review of the impact of state NP SOP regulations on health-care delivery suggest that removing restrictions on SOP regulations to provide a more autonomous NP practice environment could be an effective strategy to increase primary care capacity, improve care utilization, and potentially reduce costs, especially for states that face substantial shortages of primary care physicians and increased care demand from rural and medically underserved communities (Xue, Ye, Brewer, & Spetz, 2016). With the implementation of the ACA, 17 of 24 states predicted to have a higher than national average demand for primary care providers have restrictive NP SOP regulations (American Association of Nurse Practitioners, 2015; Huang & Finegold, 2013). Given this mounting evidence, state lawmakers and other stakeholders should consider the impact of NP SOP regulation on the delivery and cost of health care in their state. Policies to Promote Equitable NP Distribution While the expansion of state laws authorizing autonomous NP SOP is critical for NPs to fill the primary care workforce shortage, especially in vulnerable population areas, it is insufficient in and of itself. The equitable distribution of the expanding NP workforce in relation to areas of greatest need of primary care is equally imperative. Uneven distribution of the health-care workforce has been a major barrier to an adequate and efficient health-care delivery system (Bodenheimer & Pham, 2010; Huang & Finegold, 2013; MacLean et al., 2014). The equitable distribution of NPs in relation to disease burden and health-care needs is especially critical, given NPs historic and evolving role in providing primary care for underserved and vulnerable populations. Little is known about the geographic distribution of NPs, nationally, in relation to vulnerable population

4 Xue and Intrator 27 areas or the factors affecting this distribution (Everett, Schumacher, Wright, & Smith, 2009; Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003; Morgan et al., 2015). Two published studies have examined the distribution of NPs nationally, and both found great variation in their concentration across states and counties (Lin, Burns, & Nochajski, 1997; Skillman, Kaplan, Fordyce, McMenamin, & Doescher, 2012). State-level NPs per capita ranged from 1.7 to 8 per 10,000 population in urban areas and from 1.2 to 7.7 per 10,000 population in rural areas, with the highest concentrations in states in the New England and West regions (Skillman et al., 2012). Although NPs are more likely than physicians to serve in rural and underserved areas (Everett et al., 2009; Grumbach et al., 2003), studies have also shown that along with other health-care professionals, NPs are disproportionately located in urban areas or counties with large central cities (Kaplan et al., 2012; Lin et al., 1997). Several federal programs provide initiatives to encourage health-care providers to practice in underserved areas. These include the National Health Services Corps loan repayment and scholarship programs, particularly Nurse Corps loan repayment program, the Area Health Education Centers, and incentive payment programs through Medicare. The Medicare incentive payment programs consist of the HPSA Physician Bonus program, HPSA Surgical Incentive Payment program, and the Primary Care Incentive Payment (PCIP) program (Centers for Medicare & Medicaid Services, 2014). The Rural Health Clinic Services Act (1977, P.L ), which was enacted to increase the use of non-physician practitioners such as NPs in federally designated rural areas, authorizes incentive reimbursement to NPs at parity with physician services (Chapman, Wides, & Spetz, 2010). The current incentive programs and other national and states policies, which can have a strong influence on the supply of health-care providers in underserved areas, are in need of reform to stimulate NPs work in these areas. An eligible primary care physician practicing in a HPSA may receive both a HPSA physician bonus payment and a PCIP payment. However, NPs who provide primary care services in HPSAs are only eligible for PCIP programs. HPSA Medicare Bonus Payment programs should include NPs and other nonphysician providers. Moreover, the wide range of Medicaid fee-for-service reimbursements of NP services across states creates an environment that promotes disparities in care provision by NPs to Medicaid enrollees (Chapman et al., 2010). Many NPs report that payer policies had more impact on how and where they can practice than SOP regulations (Yee, Boukus, Cross, & Samuel, 2013). It is likely that low salaries are probably a major barrier to practice in primary care settings, particularly in underserved areas (Fowkes, Gamel, Wilson, & Garcia, 1994). Both state and federal policymakers need to consider payment reforms in concert with workforce development policies to boost NP practice in underserved areas and promote an equitable distribution of NP care delivery. Policy Changes Needed in NP Education Providing adequate training and fostering interest in primary care in rural or underserved areas among nursing students in advanced practice programs is vital to the development of a workforce pipeline to meet future health-care needs. Current NP education programs are at the master s level and are required to provide education to NPs in meeting nine essential core knowledge and skill competencies delineated in the national guideline The Essentials of Master s Education in Nursing (American Association of College of Nursing, 2011). The nine competencies include background for practice from science and humanities, organizational and system leadership, quality improvement and safety, translating and integrating scholarship into practice, informatics and health-care technologies, health policy and advocacy, interprofessional collaboration for improving patient and population health outcomes, clinical prevention and population health for improving health, and master s-level nursing practice (American Association of College of Nursing, 2011). Although the national guidelines include competencies in population health, the risk factors of health among vulnerable populations are very different from those of the general population. Among the general population, policy interventions are intended to alter environmental conditions or behavioral norms linked to population-level risk exposures (e.g., public smoking bans; Frohlich & Potvin, 2008). However, among vulnerable population, interventions need to address underlying socioeconomic risk factors and health risks factors (Frohlich & Potvin, 2008). Thus, the population health approach has been criticized for having the unintended consequence of exacerbating health inequalities. Evidence has shown that vulnerable populations at highest risk of disease exposure typically benefit the least from population health interventions (Frohlich & Potvin, 2008). This is because such programs typically ignore the underlying socioeconomic factors that lead to higher disease burden among vulnerable populations (Frohlich & Potvin, 2008). Researchers have, therefore, suggested to distinguish between vulnerable population health and general population health approaches, while designing public health interventions that integrate both (Frohlich & Potvin, 2008). To meet the unique and challenging needs of vulnerable populations, Van Zandt et al. (2008) have recommended the following specific essential skills for

5 28 Policy, Politics, & Nursing Practice 17(1) NPs: strong interpersonal skills, health promotion and patient education skills, patient advocacy skills, history and physical examination skills, skills to be resourceful and flexible, and cultural sensitivity. In addition, leadership skills are essential for NPs to work effectively as clinician leaders within integrative, multidisciplinary teams, an increasingly adopted model of care delivery (Esperat, Hanson-Turton, Richardson, Tyree Debisette, & Rupinta, 2012; Flinter, 2005). Despite the evolving contributions that NPs have made in advancing the health of vulnerable populations, improvements in NP education and training are essential in promoting sustained excellence in care of vulnerable populations. Indeed, the specific health-care needs of vulnerable population groups in underserved areas have not been well addressed in the current education system (Rieselbach et al., 2010). NP graduates appear to be inadequately prepared for serving vulnerable populations according to a recent survey, with 55% indicating that they were only somewhat prepared for independently and confidently caring for vulnerable populations (Sargent & Olmedo, 2013). It is critical to improve education for NPs to serve vulnerable populations. Strategies include the development of educational programs that include curriculum on vulnerable population health, service learning opportunities in underserved areas, and clinical rotations in rural or underserved settings (Dolea, Stormont, & Braichet, 2010; Grobler et al., 2009; Sheikh, 2014). Recruiting students from rural or underserved areas is also an effective strategy to increase the supply of health professionals in these areas, as students are more likely to serve their home communities after completing their education (Dolea et al., 2010; Grobler et al., 2009). Furthermore, development of NP residency training programs in safety-net settings (e.g., federally qualified health centers, nurse-managed health clinics) can effectively increase NP competency in caring for vulnerable populations and help NPs develop crucial skills to lead multidisciplinary teams (Flinter, 2010; Sheikh, 2014; Van Zandt et al., 2008). Opportunities for professional development and continuing education and training are also important in recruiting and retaining health professionals in rural or underserved areas (Dolea et al., 2010; Grobler et al., 2009). NPs practice at the forefront of health-care redesign; participation in innovative care delivery projects such as Extension for Community Healthcare Outcomes present valuable opportunities to gain knowledge, skills, and support to provide comprehensive primary and specialty care to rural and underserved populations with complex conditions such as Hepatitis C or chronic pain (University of New Mexico, 2015). The value of community-based practice and greater attention to the health needs of vulnerable populations have been advocated in graduate nursing education, which is committed to making a unique and substantial contribution to the health of society (Hall & Stevens, 1995). To this end, it is imperative to align NP education with the evolving role of NPs in health-care delivery, especially NPs historic and increasingly vital role in serving vulnerable populations. Role of NPs in Policy Advocacy for Vulnerable Populations As frontline health-care providers, NPs gain first-hand knowledge of the complexities of socioeconomic conditions associated with the health of vulnerable populations. Increased awareness of the social and economic determinants of health and health inequality affords NPs a unique opportunity to advocate for policy reform affecting vulnerable groups. It is important for NPs to recognize the value of social policies in reducing health disparities, emphasize it as a basis for practice, and advocate for it to improve public health. Health inequity is not only an issue of difference in health but also an issue related to social justice, as individuals have the right to equal access to cost-effective medical care as well as to child care, education, housing, environmental protection, and other factors that are also crucial to health and wellbeing (Braveman et al., 2011, p. S150). Moreover, equity in quality care is also of paramount importance (Wong, LaVeist, & Sharfstein, 2015). NPs active participation in advocating for both health and social policies for vulnerable populations would greatly help promote health equity in both access and quality. For example, nurses frequently testify on access and coverage issues before congressional committees (Cohen & Muench, 2012). As health policy and advocacy is one of the core essential competencies required for NPs, NPs are expected to have fundamental knowledge and skills to engage in policy advocacy. The National League of Nursing (2015) further offers a Public Policy Advocacy Toolkit to guide nurses through various levels of governmental actions. Teaching in the use of this toolkit should also be incorporated into NP curricula. Conclusions In summary, regulatory, workforce, and educational policies need to go hand in hand to build a sufficient and equitably distributed NP workforce to serve rural and underserved populations. The confluence of increasing health inequalities, health-care reform designed to address these inequalities, health professional shortages, and the historic and evolving role of NPs in providing care for vulnerable populations has created an opportunity for the nursing profession to have an even greater impact on the health of the nation. Granting NPs legislative authority to practice to the fullest extent of their

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8 Xue and Intrator 31 Sargent, L., & Olmedo, M. (2013). Meeting the needs of newgraduate nurse practitioners: A model to support transition. Journal of Nursing Administration, 43(11), doi: /01.nna d2. Sheikh, K. R. (2014). Expanding clinical models of nurse practitioner education: Service learning as a curricular strategy. JNP-Journal for Nurse Practitioners, 10(5), doi: /j.nurpra Shi, L., & Samuels, M. E. (1997). Practice environment and the employment of nurse practitioners, physician assistants, and certified nurse midwives by community health centers. Journal of Allied Health, 26(3), Skillman, S., Kaplan, L., Fordyce, M., McMenamin, P., & Doescher, M. (2012). Understanding advanced practice registered nurse distribution in urban and rural areas of the United States using national provider identifier data (Final Report #137). Seattle. WA: University of Washington Rural Health Research Center. U.S. Center for Diseases Control and Prevention. (2011). CDC health disparities and inequalities report United States (MMWR Surveillance Summaries). Atlanta, CA: Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. (2010). Introducing healthy people Retrieved from University of New Mexico. (2015). ECHO model. Retrieved from Van Zandt, S., Sloand, E., & Wilkins, A. (2008). Caring for vulnerable populations: Role of academic nurse managed health centers in educating nurse practitioners. The Journal for Nurse Practitioners, 4(2), doi: / j.nurpra VanBeuge, S. S., & Walker, T. (2014). Full practice authority effecting change and improving access to care: The Nevada journey. Journal of American Association of Nurse Practitioners, 26(6), doi: / Wong, W. F., LaVeist, T. A., & Sharfstein, J. M. (2015). Achieving health equity by design. JAMA, 313(14), doi: /jama Wright, B., Damiano, P. C., & Bentler, S. E. (2015). Implementation of the Affordable Care Act and rural health clinic capacity in Iowa. Journal of Primary Care and Community Health, 6(1), doi: / Xue, Y., Ye, Z., Brewer, C., & Spetz, J. (2016). Impact of state nurse practitioner scope-of-practice regulation on healthcare delivery: Systematic review. Nursing Outlook, 64(1), doi: /j.outlook Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse Practitioner Scope-of- Practice Laws and Payment Policies (Research Brief Vol. 13). Washington, DC: National Institute for Health Care Reform. Author Biographies Ying Xue, DNSc, RN, is an Associate Professor in the School of Nursing at the University of Rochester. Integrating her expertise in nursing and health service research, Dr. Xue s research focuses on nurse workforce issues, with the goal of developing empirical evidence to inform policies for workforce development and planning. She has investigated trends in racial and ethnic diversity, education, and job satisfaction among the national nurse workforce. She also studied the effects of organizational structure, work environment and the nature of the nurse workforce on patient outcomes. Orna Intrator, PhD, is a Professor in the Department of Public Health Sciences at the University of Rochester and a Research Health Scientist at the Canandaigua VA Medical Center. Dr. Intrator s research at the University spans the creation of measures of medical staff in nursing homes from survey data and from claims data, and studying organizational and policy factors influencing nursing home resident care processes and resident outcomes. Dr. Intrator is the creator of the Residential History File which allows tracking of patient s health services use and settings over time using claims and other administrative data spanning from Center for Medicare and Medicaid Services data (eligibility, claims, Medicare and Medicaid) through VA utilization and eligibility data. Dr. Intrator is the Director of the National VA Geriatrics and Extended Care (GEC) Data and Analyses Center (GEC DAC) which evaluates the effectiveness and costs of GEC programs, with particular emphasis on community-based programs.