by Diana J. Mason, PhD, RN, FAAN
“Relationship trumps everything,” said Jason Cunningham, D.O., Medical Director of West County Health Centers in Sonoma County, California, where consistent teams are key for staff and patients alike. West County has four Federally Qualified Health Centers that serve about 14,000 patients who are largely (over 80%) on public insurance coverage or uninsured. Close to 60% of their patients with chronic illnesses have a history of trauma that contributes to their difficulties in managing their illnesses and caring for themselves.
Some years ago, the primary care practitioners (physicians, nurse practitioners, or physician assistants) were providing care with or without the support of a medical assistant, while a registered nurse (RN) was doing triage. In recognition that patients need more than a 20 minute visit with a practitioner, West County reconfigured their teams and the roles each person played. As a result, it has been able to improve patients’ chronic care management, clinical outcomes for the population, and financial outcomes.
How It Works
Teams now consist of a practitioner (1.0 FTEs or full-time equivalents); RN (1.2 FTEs); medical assistant (1.75 FTE) who “manages the office experience for patients and providers alike”; behavioral health worker (1.0 FTE), and “care team representative” or front office staff (1.75 FTE) who also are trained in customer service and motivational interviewing; and community health workers (.33 FTE) who can be in the office, the community, or patients’ homes. But the patient, not the practitioner, is at the center of this team.
Each team has a consistent panel of patients whom it builds trusting relationships over time. All team members have a high degree of autonomy and independence and can refer patients to each other — not just to the practitioner. The relationships among team members foster trust in their respective capabilities and shared “knowing” about the patients.
A significant change in the team composition and roles has been the RNs. “They do the messy stuff,” as one nurse told us. “They can do everything, but shouldn’t.” For example, the RN can do all triage, but the front office staff manages the non-clinical triage, freeing the RN to do patient teach and counseling, coaching on chronic illness management, and complex care management, as well as the clinical triage. The RNs make home visits as needed, “moving primary care outside the four walls,” including addressing some of the social determinants of health that compromise their patients’ health
Preparing RNs for Primary Care
One of the greatest challenges West County has had in creating and maintaining these teams has been finding and keeping qualified RNs. Few RNs are educated in their basic nursing programs to work in primary care. But that may be changing.
In 2017, the Josiah Macy, Jr. Foundation published a report, Registered Nurses: Partners in Transforming Primary Care, based upon a 2016 invitational conference with various stakeholders. The report acknowledged that undergraduate nursing education is not doing an adequate job of providing a curriculum that includes didactic and clinical experiences in primary care. For decades, nursing education has been preparing nurses to serve in acute care hospitals — that’s what our nation has emphasized and paid for. A survey of undergraduate nursing programs found that few provide the breadth and depth of primary care experiences that will be needed to transform primary care. (The survey is included in the final conference report.) Most schools have not hired faculty with experience in primary care except as nurse practitioners (NPs), and this is a different role than what is needed of RNs who are not prepared for the advanced practice role of a NP.
But the challenge doesn’t just rest at the feet of nursing schools. The report includes the following recommendations:
- Leaders in health care, nursing education and health systems must foster a culture that “elevates primary care in RN education and practice.”
- Primary care practice leaders must redesign their practices to use RNs in thoughtful ways in response to patient needs in primary care. Redesigns need to have the support of payers and policymakers, including regulators. The Foundation commissioned a paper by health economist Jack Needleman on the evidence for a business case for using more RNs in primary care. The paper is included in the final report.
- RNs in acute care must have access to retraining programs that will help them to transition from the hospital to primary care. This is particularly so for a seasoned RN whose clinical experience would be an asset to a primary care practice.
One of the most exciting discussions at the conference and in the report is the potential impact of partnerships between nursing schools and primary care practices that can have a mutual benefit. Through joint or shared appointments, faculty can work in primary care practices and help to redesign their care, measure outcomes, and supervise nursing students. Registered nurses and others from the practice can help to teach course content, provide clinical instruction, and work with the faculty on various aspects of the practice redesign. The partners could also develop and provide training programs for RNs working in other settings who might find primary care a more attractive work experience. Why? Few RNs in other settings are able to function autonomously in highly functioning teams, able to build long-term relationships with patients, and derive the job satisfaction that comes with seeing patients progress. Build it and they will come.
Ready, Set, Go!
There are other models of primary care practices that have been transformed by using RNs in enhanced roles. Despite West County’s success in how it has used RNs, we continue to hear from those leading primary care practices, including CEOs of FQHCs, that they can’t recruit and retain qualified RNs. Transforming primary care is not a linear process. We need to build the partnerships that will test new models, advocate for payment approaches that reward improved outcomes, and support health care teams that keep their focus on what patients, families and communities need and want.
Diana J. Mason is the Senior Policy Service Professor and Co-Director of the Center for Health Policy and Media Engagement at George Washington University School of Nursing, and Professor Emerita at the Hunter College-Bellevue School of Nursing. She is a member of the Board of Directors of the Primary Care Development Corporation. Jason Cunningham was a participant in the 2016 Josiah Macy Jr. Foundation conference.
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