When I Put On My Clinician Hat (or rather white coat)

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.