The Institute of Medicine, in 2001, declared that: “the American health care system is in need of a fundamental change.” Their report identified significant changes in health care requirements for our nation. For many decades, the focus of health care has been on the management of acute episodic illness. Now, the requirements of our population have changed to include health promotion/disease prevention and chronic disease management. This shift in the focus of health care argues for a change in health care service delivery. It has long been known that to achieve optimal patient outcomes, health care should be patient-centered.
Currently the most discussed patient-centered model is the Patient-Centered Medical Home (PCMH). The PCMH is an approach to providing comprehensive preventative and primary care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. With health reform passing in 2009, attention has now turned towards this model to provide the U.S. population with a regular source of primary care, which is associated with better health outcomes at lower costs.
There are two inherent problems facing the U.S. as a whole. The first deals with the premise of the Affordable Care Act bringing an estimated 32 million people of those currently uninsured in to health care system by 2019. But insured or not, they’re going to have trouble finding a doctor. Passage of national health reform elevated the problem of the primary care doctor shortage that must be solved if federal health care reform is going to work, says Dr. Lori Heim, president of the American Academy of Family Physicians. “If current trends continue, there will be a shortage of about 40,000 family doctors by 2020,” she says.
One of the hot topics occurring in the health care deals with figuring out appropriate leaders of the Patient Centered Medical Home (PCMH). With the recent report by the IOM advocating for independent practice by nurse practitioners via nurse-doctor substitution, many physician groups, including the AAFP and AMA, have come forth with strong statements advocating against the IOM report and independent practice by CRNPs. However, Jan Towers, director of health policy and professional affairs at the American Association of Nurse Practitioners says, “Nurse practitioners produce similar results when compared to physician-led primary care practices, but we continue to be a group of providers that are underutilized.”
Currently, Nurse practitioners are the fastest growing segment of primary caregivers. The number of primary care nurse practitioners is increasing at a rate of 9.44 percent per capita, compared to 1.17 percent for physicians. It is estimated that about 80 percent of the workforce is in a primary care setting (Tobler, 2010). What is not discussed here is the impact being created on the nursing workforce as a whole due to this push for Nurse practitioners. Numbers produced by the American Association of Colleges of Nursing (AACN) that the IOM, CRNP advocates, and the media fail to mention that according to AACN’s report on 2010-2011 Enrollment and Graduations in baccalaureate and Graduate Programs in Nursing, nursing schools turned away 67,563 qualified applicants from baccalaureate and graduate nursing programs in 2010 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. Concurrently, In the July/August 2009 Health Affairs, Dr. Peter Buerhaus et al found that despite the current easing of the nursing shortage due to the recession, the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025.
Expanding the scope of practice for nursing without addressing the current shortage of nurses within the current scope of practice will only spread the nursing workforce even thinner – and in my opinion, will only compromise patient care further than it already does. Increasing advocacy efforts for independent practice and encouraging current nurses to pursue higher education to provide outpatient primary care in the PCMH without increasing the amount of resources and faculty to contribute to a larger nursing workforce will lead to adverse unintended consequences.
Below are two videos discussing the two different medical home models; the first is from the nurse practitioners perspective the second is from the physician perspective. Enjoy. Lee
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