According to the American Association of Nurse Practitioners (AANP), primary care nurse practitioners (NPs) see more than 1 billion patients annually across the United States. Ninety percent of the nation's 325 000 NPs are in primary care, constituting one-quarter of the total primary care workforce of providers. Most NPs accept Medicare and Medicaid and serve in rural and historically underserved communities.1 Rural communities rank the highest as primary care shortage areas, with millions of patients living in these communities and lacking access to affordable and reliable healthcare.2 Many states with rural, primary care provider shortage communities have outdated laws in place that limit patient access to primary care, by providing financial and restrictive barriers to NPs establishing clinics in these areas.1 In writing this column this month, I reached out to Dr Sophia Thomas, past-president of the AANP and primary care provider in her community. I asked Dr Thomas to share more about her role in this community and the types of patients she serves (email communication with S. L. Thomas DePaul Community Health Center, Kenner, Louisiana, May 1, 2021).
Dr Thomas practices in Kenner, Louisiana. She shared her story as a primary care NP, "I have been a family and pediatric primary care nurse practitioner for 26 years, and much of my practice has focused on providing primary care in rural health clinics and community health centers." Community clinics, like Dr Thomas', focus on providing care for vulnerable patients, patients from diverse backgrounds, socioeconomic situations, and ethnicities. Primary care NPs are often the initial point of contact for patients seeking healthcare. These NPs are responsible for ongoing preventive care, as well as diagnosis and treatment of acute and chronic illnesses, including prescribing medications and other therapies. In addition, as gatekeepers for healthcare, primary care NPs maintain thorough patient records, coordinate care across disciplines, and refer to specialists as needed. She states that "coordination and continuity of care is so important, building patient rapport and relationships over the course of time, and through this process, the long-term patient-provider partnership becomes synergistic in helping to improve overall outcomes."
Over the past year, I have had the opportunity to observe Dr Thomas in action, caring for patients and families. She easily picks up the phone to call specialists or other providers with whom she is coordinating care. Dr Thomas explains the care being provided carefully with each patient. She reviews each treatment, each medication and the purpose, what to expect, and when to call if there are questions. If she is referring a patient to a specialist, she discusses the purpose and what to expect. Dr Thomas helps to allay fears and concerns, but also very practically helps to coordinate appointments and transportation. She partners with community organizations to ensure that she has access to their healthcare needs, such as medication, medical equipment, home health services, nutritional counseling, and housing, and helps to coordinate these services effectively. "Primary care NPs focus on several aspects of the health of patients, and we take a very holistic approach, viewing the patient as a whole person, including environmental and social factors that could impact healthcare outcomes. One aspect of care is health promotion; monitoring patients' health, educating patients, and setting goals with patients to empower them to improve their health outcomes education are key in health promotion, and as NPs in primary care, teaching patients about health risks as well as healthy lifestyles is key in health promotion, as well as in disease prevention. The COVID-19 pandemic highlighted the health disparities we have in this country, when we saw people of color dying of COVID at a higher rate than others. This population has historically had higher rates of obesity, diabetes, heart disease, kidney disease, and asthma, among other diseases. The statistics have not changed since I was in NP school over 26 years ago; therefore, we must now take this knowledge and rededicate ourselves to promoting health equity and access for all patients to improve healthcare outcomes in this country."
As Dr Thomas shared her story, it helped me, as an acute care NP who works in a hospital setting, realize even more the importance of having NPs in the community. Her patients depend on her for ongoing healthcare maintenance and prevention of disease. She is easily approachable and compassionate and strives to know each patient as an individual with unique circumstances and needs. Her clinic is busy with patients from her community and from many rural areas.
With an NP like Dr Thomas in the community, and now with more than 325 000 NPs in the country, why then, I ask, is it so difficult for patients across the United States to find access to primary care? The main reason is that there are state laws in place that restrict NPs' ability to practice in rural communities, limiting patient access to NP care. Even in several states with large rural areas, such as my own home state of Tennessee, NPs are not allowed to practice to the extent of their advanced nursing education, clinical training, and board certification. For example, in Tennessee, NPs must contract with a physician to have their charts reviewed every 30 days. The retrospective chart review has no impact on the patient's care, and the payment for the physician's service can be crippling to the NP's practice, as, in Tennessee, the payment for the chart review services is unrestricted, whereas if NPs could practice to the extent of their education and board certification, NPs could provide much more accessible care. According to AANP, modernizing these laws would allow more NPs to practice in rural areas, collaborating with therapists, physicians, specialists, and other clinicians as needed for comprehensive treatment of each patient.1 The 2021 Future of Nursing Report,3 states that removal of regulatory barriers to care will substantially increase health equity and access to advanced nursing care across all settings. The report urges states to allow nurses to practice to the full extent of their education, clinical training, and board certification and that, until this occurs, preventable gaps in access to care will continue, stating "millions of people who need healthcare will be unable to obtain needed care as readily as others who happen to live in states where NPs' scope of practice is not restricted."3(p87)
Nurse practitioners are essential members of the healthcare community. Their value is felt every day by patients and families who are able to access their care. Primary care NPs provide advanced nursing care that is much needed in communities across the United States. Patients are choosing NPs as their primary care providers for a reason, for many reasons, and in return, they are receiving quality, comprehensive, and well-coordinated care. It only makes sense that we as a country would eliminate barriers so that patients can more easily access the comprehensive care a primary care NP provides.
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