Nurse-Led Medical Homes: Current Status and Future Plans

Laurie Scudder, DNP, NP

Disclosures

May 27, 2011

In This Article

What Is a Patient-Centered Healthcare Home?

What is a "medical home" and which clinicians are qualified to lead the home team? The concept of a patient-centered medical home (PCMH) is not a new one and, for as long as this model of care has been discussed, the issue of who can lead a PCMH has been debated. First introduced in 1967 by the American Academy of Pediatrics as a model of care for children with specialized health needs and envisioned as a physical place, the concept is now used to describe a partnership between clinicians, patients, and families that is accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective.[1]

This model of care is now promoted by most major medical groups and typically described in language that suggests that it should include a physician as "head" of the medical home.[2] The concept has gained new importance as a result of its prominent inclusion in the 2010 Affordable Care Act, which created a number of demonstration projects, most notably for children and those with chronic disease.

Experts discuss nurse-led medical homes before an audience of enthusiastic NPs at George Washington University on April 5, 2011.

Nursing groups have long noted the need for inclusion of nurses in medical homes, including as leaders. This recognition was the impetus behind a recent meeting titled "Nurse-Led Medical Homes -- Increasing Access to Quality Care." Co-hosted by the Nursing Alliance for Quality Care (NAQC) and the American Academy of Nurse Practitioners (AANP), with support from the Robert Wood Johnson Foundation, this day-long event was held at George Washington University and brought together nurses and other stakeholders from around the country.

The National Committee for Quality Assurance (NCQA) plays an integral role in promoting PCMHs as the standard of care. NCQA defines a PCMH as "a model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has a relationship with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient's health care needs and arranging for appropriate care with other qualified clinicians. The medical home is intended to result in more personalized, coordinated, effective and efficient care."[3]

The History of Nursing in the Medical Home Model

Note the use of the term primary care "clinician" in the NCQA definition, a change from earlier literature that referred to primary care physician. As Nancy Rothman, EdD, RN, Independence Foundation Professor of Urban Community Nursing at Temple University and a consultant to the Philadelphia Health Management Network noted during a presentation at the NAQC/AANP event, speaking as a board member on behalf of the National Nursing Centers Consortium, this change was announced October 22, 2010.

What were the factors that led to this change despite resistance from organized medicine? Dr. Rothman cited a number of factors including recognition by policy makers that nurse‐led medical homes both save money by lowering hospital and emergency department admissions and increase access by enhancing the ability of nurse practitioners (NPs) to fill gaps in primary care for vulnerable populations. Indeed, a solution is not possible without NPs who in 2005 were estimated to comprise approximately one quarter of the primary care workforce.[4]

The recognition of the role of nurses by NCQA followed a long and tortuous battle by nurses. The first medical home demonstration projects were mandated by the Tax Relief and Health Care Act of 2006 and the Medical Homes Act of 2007. Projects were selected to provide coordinated family-centered care to both Medicare and State Children's Health Insurance Program recipients with chronic illness requiring regular care. The legislation only allowed for physicians to participate in these demonstrations.[5]

In 2008, the Medicare Payment Advisory Commission (MedPAC) issued a report on primary care and the demonstration projects, defining primary-care-focused practitioners as physicians, NPs, and physician assistants.[6] The report recommended that medical homes meet stringent criteria including:

  • Furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services);

  • Conduct care management;

  • Use health information technology for active clinical decision support;

  • Have a formal quality improvement program;

  • Maintain 24-hour patient communication and rapid access;

  • Keep up-to-date records of beneficiaries' advance directives; and

  • Maintain a written understanding with each beneficiary designating the provider as a medical home.

While the Senate Finance Committee, in hearings conducted subsequent to the release of the MedPAC report, considered the inclusion of NPs in demonstration projects, a revision to the previous guidelines excluding providers other than physicians failed to pass.

Efforts to include NPs subsequently moved to the states, with Iowa, Minnesota, and Washington initiating projects that included NPs. The 2010 Affordable Care Act contained many provisions designed to promote improved access, increased quality of care, and decreased costs, including PCMHs. The law established a grant program to establish community-based interdisciplinary teams to support primary care practices. Medical homes were described as focusing on primary care and sharing common elements including a primary care clinician (physician, NP, or physician assistant) to oversee and coordinate patient care.

As a result, NCQA re-reviewed applications from 8 Pennsylvania NP‐led primary care practices that they had previously reviewed as part of the Pennsylvania Governor's Chronic Care Initiative in southeast Pennsylvania in 2009. All were awarded recognition.

Dr. Rothman cited a number of factors instrumental in this shift by NCQA:

Grass roots level advocacy. All 8 clinics recognized by NCQA are members of the National Nursing Centers Consortium (NNCC) and benefited by advocacy from an organization whose mission is to advance nurse‐led healthcare. For a number of years prior the NCQA application, NNCC had waged an aggressive campaign of education about the role of advanced practice nurses at both the state and federal level that included letter-writing campaigns, legislative rallies, attendance at state legislative hearings, submission of testimony, and forming coalitions with other advanced practice nursing groups and government officials. Their successes led to the inclusion of advanced practice nurses in the definition of primary care provider in Pennsylvania law and the end of regulation of NP practice by the Pennsylvania Board of Medicine and to prescriptive authority.

NNCC's efforts were also enhanced by a long-term relationship with then-Governor Ed Rendell that contributed to the inclusion of nurse-led clinics in the Governor's Chronic Care Initiative. In addition, Philadelphia region nurse-managed clinics were positioned well to participate in the Governor's Chronic Care Initiative as NNCC had worked with local funders to secure funding for data improvement activities and electronic medical records over the preceding 6 years.

Health reform in Massachusetts. In August 2008, Massachusetts enacted a healthcare bill that dramatically expanded services leading to the lowest rate of uninsured in the nation. That same law expanded use of NPs and other providers. A subsequent Rand Report projected that more widespread use of these providers with expanded scopes of practice could result in $4.2 to $8.4 billion in savings for the Commonwealth of Massachusetts.[7]

The Patient Protection and Affordable Care Act. The Affordable Care Act defined "Nurse‐Managed Health Clinic" in the Public Health Service Act (Section 330) for the first time and created a new $50 million grant program for nurse-managed primary care and wellness centers that serve vulnerable and underserved populations.

Institute of Medicine's The Future of Nursing Report.[8] The messages of this paradigm-changing report were clear. Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States. Effective workforce planning and policymaking require better data collection and information infrastructure.

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