1. Sofer, Dalia


But political and fiscal challenges remain.


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Community-based clinics led by advanced practice registered nurses (APRNs) have a positive impact on health outcomes, patient satisfaction, and access to care, according to a recent systematic review. Whether these clinics are also cost-effective, however, wasn't clear since few of the studies in the review examined that question.

Figure. Family NP Mi... - Click to enlarge in new window Family NP Michelle Mullin listens to the heart of an incoming freshman during his physical at the health clinic located inside Normandy High School in Normandy, Missouri. Photo (C) Associated Press.

The researchers' findings were based on a sample of 15 studies from Sweden, the United Kingdom, the United States, New Zealand, Canada, and Australia published between 2006 and 2016. They documented generally positive self-reported or nurse-observed health outcomes, including behavioral changes in patients that led to better health. Examples of these were safer sex practices, smoking cessation, and improved self-care. Overall, 10 of the 12 studies measuring patient satisfaction were positive, documenting patient sentiments such as a "sense of security," feeling "trust and respect," and "gaining insights into own health." Access to the clinics and services was also perceived positively. Two studies recorded patient dissatisfaction, including "unfulfilled expectations" and "feeling controlled and exposed." Cost-effectiveness was measured by only two studies; both showed savings but the sample was too small to draw conclusions. The authors called for more studies to examine this important question.


Cheryl Fattibene, chief nurse practitioner officer at the National Nurse-Led Care Consortium (NNCC), which represents 152 nurse-managed health clinics, believes their positive financial impact on the health care system is considerable but overlooked. About 65% of NNCC-member clinics operate in medically underserved communities in urban and rural settings and on Indian reservations. "Thanks to the services that these health centers provide, emergency room costs at hospitals go down," Fattibene told AJN. Moreover, the Affordable Care Act coupled with Medicaid coverage expansions in many states has improved the financial viability of nurse-led clinics since "the more people who are insured, the more the clinics can get paid," Fattibene says. The NNCC is encouraging nurse-led clinics to qualify for payment under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which would reimburse clinicians based on patient health outcomes and quality of care rather than on services performed.


A challenge to expansion of nurse-led clinics is the degree to which APRN scope of practice regulations vary from state to state. "Some standardization would be helpful," says Fattibene. "You are not going to get consensus when you have 50 states with 50 different opinions." The strongest pushback to cross-state standardization, according to Fattibene, has come from the American Medical Association, which last fall adopted Resolution 214 in opposition to the APRN Compact, which would permit licensed APRNs to practice in other compact states.


"APRNs tend to focus on wellness and prevention," Fattibene says, "but the health system, in its current state, is designed to deal with the very sick. If we continue on this path, she continues, "we are going in the wrong direction."-Dalia Sofer




Randall S, et al Int J Nurs Stud 2017 73 24-33