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By Andrea Brassard, DNSc, MPH, FNP, Strategic Policy Advisor, Center to Champion Nursing in America at AARP

In my role as Strategic Policy Advisor for the Center to Champion Nursing in America, I think daily about the need to expand consumer access to advanced practice registered nurses (APRNs). But it is when I put on my clinician hat (or rather white coat) that I see the critical link that must be made between ensuring APRNs can provide the services for which they are trained and experienced and ensuring that Americans have access to health care coverage. This was never clearer than last week when I volunteered at the DC Cares Free Clinic, sponsored by the National Association of Free Clinics. More than 1,000 people came to this one-day free health clinic to get the basic health services they can't afford or are otherwise denied because they have no insurance. The District of Columbia has 57,200 residents without insurance—and there are millions of uninsured in nearby Maryland and Virginia.

As a nurse practitioner, I was there as a clinician to provide primary care assessment, diagnosis and to work with patients on developing treatment plans. At the DC Cares Free Clinic, nurse practitioners and physician assistants worked side by side with physicians, each clinician providing primary care to the more than 1,200 patients we saw that day. In the District, APRNs can practice independently; that is, we can diagnose, prescribe and otherwise treat patients without physician oversight.

As I began to see patients, the experience underscored what I’ve long known—what patients without access to health care will do to get by and the health risks these actions pose.

The question—"what meds are you taking?" became "what meds were you taking before you ran out?"  One man borrowed diabetic medications from his brother and friends. One woman who I’ll call Louise (not her real name) ran out of her thyroid medication just that morning. Louise told me that she has seen a veterinarian (for her cats) more often than a physician since she lost her job. I was able to write $4 and $10 generic prescriptions for Louise. Louise was 54 and had not had a mammogram in 3 years.  She put off her last mammogram and then lost her full time job two years ago. I was able to refer Louise for a free mammogram (and a Pap smear) at Howard University Cancer Center. The other screening test that Louise needed is a colonoscopy, which is likely out of reach for her until she can obtain private health insurance, or until her “Welcome to Medicare” exam. 

At the end of my shift I introduced myself to Nicole Lamoureux, Executive Director of the National Association of Free Clinics. Nicole and I recently were appointed to a Department of Health and Human Services Committee to review and update the criteria used to define medically underserved areas and health professional shortage areas. The committee was formed as part of the implementation of the Patient Protection and Affordable Care Act.

You would not think that the District of Columbia was a medically underserved area. Yet, according to the DC Department of Health, approximately 45% of the population of the District resides in a medically underserved area.

APRNs, such as nurse practitioners, should be an important point of access for our underserved communities. In fact, DC has the largest percentage of nurse practitioners per population in the nation. Karen Scipio-Skinner, the Executive Director of the DC Board of Nursing thinks that the large number of NPs per population is due to the District’s APRN rules and regulations. APRNs can practice in the District without the barriers found in other jurisdictions. They can practice independently without physician supervision or collaboration agreements and prescribe medications without protocol requirements.

This is good news for consumers of health care. The District, like a number of states across the country who also allow independent practice for nurse practitioners, is well-positioned to take advantage of more funding for primary care and community-based health centers found in the recently passed Patient Protection and Affordable Care Act.

With Susan Hassmiller, PhD, RN, FAAN, Director of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine.

As senior advisor for nursing for the nation's largest health care philanthropy, the Robert Wood Johnson Foundation, Susan B. Hassmiller has had nursing in her blood from an early age. From candy striper to nurse's aide to nurse to the director of the RWJF Initiative on the Future of Nursing, at the Institute of Medicine, Hassmiller is spending her summer vacation in Europe, retracing the steps of the legendary Florence Nightingale.  In this and upcoming posts in the American Journal of Nursing's Off the Charts blog, Hassmiller reports on her inspiring trip to London, at Embley Park and Istanbul, Turkey and what it means to her work today. Below is an excerpt from Sue's first post.

Eighteen years old and ‘hot to trot.’ That’s what I thought I was. Having just been admitted into nursing school, I was set to change the world…one patient at a time. They tried to teach me about Florence Nightingale, but she was someone from the past…not likely to help me learn to start IVs, put in catheters, or run ventilators. If there were iPods back then, I would have used mine to avoid lessons about how Florence Nightingale changed the face of nursing forever. Read the full post here.

Update: Sue Hassmiller answers six questions about her trip for RWJF's Sharing Nursing's Knowledge (August 2010).

By Tine Hansen-Turton, MGA, JD, Chief Executive Officer and Ann Ritter, JD, Director, Health Center Development & Policy, National Nursing Centers Consortium

The passage of the Affordable Care Act means that more than 30 million additional Americans will have health insurance by the year 2014. Can our primary care system handle the demand?

In Massachusetts, passage of a universal insurance plan in 2006 completely overwhelmed the Commonwealth’s existing supply of primary care physicians, and the effects are still being felt. In 2009, only 44% of internists in Massachusetts were accepting new patients. The average wait time for a new patient to get an appointment was 44 days.

Nurse practitioners can provide care that is similar in scope to a primary care physician in all 50 states.  Health care innovators have capitalized on nurse practitioners’ ability to provide high-quality care in independent settings such as convenient care clinics (also known as retail-based clinics) and nonprofit nurse-managed health clinics that serve vulnerable patients. Nurse practitioners in these settings have already served over 20 million people in the U.S., and they have the capacity to reach millions more.
 
How can nurse-led health clinics reach their full potential? A few common-sense policy reforms could go a long way towards increasing access to primary care for all Americans.
 
First, insurance companies should do a better job connecting their enrollees to nurse practitioners. We conducted a national survey of insurance companies last year and found that nearly half of all major insurers in the U.S. do not credential or reimburse nurse practitioners as primary care providers. 
 
This means that patients who want to see a nurse practitioner for primary care don’t have the flexibility to do so. It also means that many patients whose needs could be addressed in a cost-effective way by nurse practitioners have to wait weeks or months for an appointment with a physician.
 
Many of the insurers who refuse to recognize nurse practitioners as primary care providers are Medicare and Medicaid insurers. At the same time, nurse-led practices have been excluded from “medical home” projects designed to improve health care quality for seniors and other patients. Nurse practitioners are especially well-suited to provide affordable primary care to patients with chronic conditions. At a time when everyone is looking for better ways to control health care costs, we should make it easier for people with Medicare and Medicaid to choose a nurse practitioner as their primary care provider.

By Sheila P. Burke, RN, MPA, FAAN, Faculty, Harvard Kennedy School of Government; Sr. Policy Advisor, Baker Donelson

Since its creation in 1965, Medicare has provided support for nursing education. Back then, the majority of nurses were educated through hospital-based diploma programs.

Over the past 45 years, Americans’ health care needs have changed, and the nursing profession has responded to meet those needs. Americans are aging, experiencing more complex health conditions, and managing multiple chronic conditions. Simultaneously, their health care is increasingly delivered outside of hospitals, in an array of community settings—clinics, ambulatory care centers, and patients’ homes. Consequently, nursing education programs in our nation’s colleges and universities have gradually replaced hospital-based diploma programs, and the number of RNs graduating from diploma schools has declined. In 2007, only four percent of registered nurses were trained in hospital-based diploma programs.

Until recently, Medicare reimbursement for nursing education had not kept pace with our changing health care landscape, continuing to primarily invest nursing education dollars in diploma programs. But, with the passage of health care reform, also comes an important recognition that advanced practiced registered nursing (APRN) skills are needed for the Medicare population. APRNs, nurses with advanced graduate education and training, can provide primary care, chronic care management, transitional care and care coordination.

The Medicare Graduate Nurse Education Demonstration Program aims to increase the number of highly-skilled APRNs to care for Americans by providing $200 million to bolster the training of these key health care professionals.

It received little attention in mainstream health care media coverage, but what occurred was nothing short of transformative. The way Medicare pays for health care truly sets the bar for our entire health system. The Patient Protection and Affordability Care Act breaks the federal funding barrier for graduate nursing education and targets dollars toward educating nurses with the specific skills needed to meet the needs of Medicare recipients. In the end, patients and the nursing profession will be better for it.