Health Services Research & Development

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Response to Commentary

The use of non-physician providers to increase access to health care is not unique to Veterans. A shortage of physicians specializing in primary care, poised to reach crisis proportions by 2025, has led to medical facilities calling upon nurse practitioners (NPs) and physician assistants (PAs) to fill the gap.1 Varying degrees of limitations imposed by boards of nursing and medicine nationwide create additional challenges to meeting the demand of aging, chronically ill citizens. Coupled with the shortage of primary care physicians, these regulatory inconsistencies are one of the reasons VHA moved to exert federal supremacy in providing full practice authority (FPA) to registered nurses (RNs), including NPs, clinical nurse specialists (CNSs), and certified nurse midwives (CNMs). PAs are seeking the same authority. VHA took this step with the goal of improving access to care for Veterans as well as meeting the Institute of Medicine's call to allow practice to the full scope of licensure.

Substantial literature demonstrates that there is not a significant difference in the quality of care provided between these practitioners. However, there is a paucity of literature to support whether this revised model of care will achieve the same levels of satisfaction or efficiency for Veterans or providers. One study conducted in 2010 found that Veterans preferred being seen by NPs; however, the authors attribute this result to the tendency of NPs to focus on health promotion, and to their attention to Veteran concerns.2 The authors appropriately note these characteristics are easily taught to other professions. However, there are no subsequent reports of how the implementation of Patient Aligned Care Teams (PACT) may have changed this perception nor has there been sufficient time to determine whether FPA has had an impact on providers, Veterans, or budgetary issues, much less Veterans' access to health care.

Additional research is needed to fully understand the role of NPs in providing care to chronically ill Veterans. Hundreds of NPs manage primary and specialty care clinics throughout VHA, but a review of the Cochrane database finds no conclusive evidence on the efficiency or effectiveness of this delivery mechanism. Conversely, care coordination is seen as encompassing prevention, education, and management of chronic disease. Care coordination efforts by RNs is well documented in the literature, even more so since the Affordable Care Act established this model of care as a sound method for managing complex patients. In addition, the Centers for Medicare and Medicaid Services (CMS) determined in 2015 that "non in-person care" will be reimbursed when provided to individuals with two or more chronic illnesses when these conditions place the patient at an increased risk for exacerbation, hospitalization, or death. This guidance has expanded the use of telehealth and other forms of virtual care exponentially.

Hass and Swan suggest that RNs have functioned as care coordinators for years, but only received recognition following a study of RNs' roles in ambulatory care.3 One consequence of the informal nature of nursing's role is a lack of standardization in implementation, which further inhibits the ability of researchers to evaluate the impact of nurses on care coordination. Measures of quality for ambulatory nursing care continue to be elusive, although the Healthcare Effectiveness Data and Information Set (HEDIS) provides some measures for the interprofessional team.

One aspect of the expansion of the RN role in ambulatory care that deserves further exploration is the management of stable chronic disease by protocols. Such protocols can enable an RN to obtain laboratory results and provide routine management to patients with hypertension or diabetes, for example. If the patient is stable and laboratory results are normal or unchanged from previous visits, the RN can enter these results into the record while providing any needed education for the patient. However, any changes in patient status would require an elevation of the level of care. There is no evidence suggesting that this practice would or would not work, and additional research is needed to evaluate its impact on quality of care, as well as patient and provider satisfaction with this model. The advantage of this model may lie in allowing unstable patients additional time with a physician, NP, or PA while ensuring adequate monitoring for those with stable chronic disease.

Allowing nurses to practice to the full extent of their licensure and education will require research to determine the best models for delivery of this care while maintaining patient safety and quality. However, allowing this scope of practice is critical to ensuring access to health care for Veterans and civilians alike.

  1. IHS Inc., "The Complexities of Physician Supply and Demand: Projections from 2013 to 2025," Washington, DC: Prepared for the Association of American Medical Colleges, 2015.
  2. Budzi D, Lurie S, Singh K and Hooker R, "Veterans' Perceptions of Care by Nurse Practitioners, Physician Assistants, and Physicians: A Comparison from Satisfaction Surveys," Journal of the American Academy of Nurse Practitioners 2010; 22: 170-6.
  3. . Haas SA and Swan BA, "Developing the Value Proposition for Registered Nurse Care Coordination and Transition Management Role in Ambulatory Care Settings," Nursing Economics 2014; 32: 2, 70-9.

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