Nurse-Led Medical Homes: Current Status and Future Plans

Laurie Scudder, DNP, NP

Disclosures

May 27, 2011

In This Article

Does Quality of Care Increase in the PCMH Model?

While an improvement in quality of care along with a decrease in cost in the PCMH model seems intuitive, there is concern that the largely cross-sectional, observational data available do not provide clear and compelling evidence that that is the case. There is, however, evidence for the effectiveness and importance of many of the key characteristics of the model, which is aligned with the framework described in the Wagner Chronic Care Model.[9]

The Patient-Centered Primary Care Collaborative (PCPCC), a consortium of several physician primary care groups, notes that an increase in primary care services, though not necessarily delivered in practices designated as PCMHs, is associated with improved health on a population level.[10] The Commonwealth Fund studied adults with a medical home though the data were not restricted to practices designated as PCMHs by NCQA. They concluded that access, receipt of recommended preventive services, and management of chronic conditions were all improved for patients with medical homes.[11] A summary paper commissioned by PCPCC concludes that data are indeed sufficient to support a conclusion that PCMHs do improve quality, access, and cost.[12]

Quality of Care in NP-Led PCMHs

The Institute for Nursing Centers (INC) was formed in 2003 with a goal of promoting direct access to high-quality, affordable, and cost-effective healthcare services to the nation's community through the development and promotion of nurse-managed health centers (NMHC). Recognizing the small size of many NMHCs and the difficulty that this poses for these centers to tell their stories, INC has established a national database for NMHCs to track standardized data. With financial support from the W. K. Kellogg Foundation, INC convened an invited group of experts that included representatives from the American Association of Colleges of Nursing, the Agency for Healthcare Research and Quality, Bureaus of Primary Health Care and Health Professions, the Veteran's Administration, and others for the purpose of developing the first standardized clinical and financial data set for all primary care NMHCs nationally.[13]

Joanne Pohl, PhD, ANP-BC, Professor, The University of Michigan School of Nursing, described challenges that contribute to the result that this service is also, too often, invisible due to policies in the healthcare system. Challenges include:

  • Patchwork of reimbursement mechanisms in the United States and addressing the needs of the uninsured;

  • The complexity of a healthcare system that doesn't consistently recognize nursing for full reimbursement; and

  • The state-by-state variance in NP policy issues (scope of practice, reimbursement regulations).

Dr. Pohl reported data collected by INC over a 4-year period from 42 centers in 23 states representing over 600,000 patient visits, noting the wide range of practice settings and patient populations served. While patient diagnoses are similar to those reported in other primary care settings, NMHCs differ dramatically from data reported by the National Ambulatory Medical Care Survey for physician-led practices in their payer mix, with uninsured patients representing fully one third of patients served. Medicaid patients make up the next largest percentage, with the remainder representing a mix of Medicare, commercial insurance, and service contracts. This payer mix more closely resembles data from Federally Qualified Health Centers, adding weight to the argument that these centers are providing a much-needed service to patients unlikely to be served in other settings.

Revenue derived from patient care, on average, provided less than half of necessary income for NMHCs, with other sources such as grants and donations of out-sized importance in allowing these centers to continue to operate.

For the study of quality of care, 15 of the larger NMHCS were solicited and 9 agreed to participate.[14] All of the centers served a large proportion of minority patients and, across centers, approximately one third of patients were uninsured. The study utilized protocols and tools based on Healthcare Effectiveness Data and Information Set (HEDIS), a widely used standardized performance measurement system developed by NCQA for ambulatory health services.

Through analysis of administrative data, standardized audit protocols, and random sampling of charts, this assessment approach measures both outcome and process quality measures. As Dr. Pohl noted, this measure has some limitations in application to NMHCs because the HEDIS protocol assumes high-volume, managed-care services with high continuity. In contrast, NMHCs are typically small practices with fee-for-service arrangements and patients who often are seen sporadically and episodically.

Quality outcomes data were collected for the following areas:

  • Breast cancer screening: mammogram ordered and obtained during the reporting period;

  • Cervical cancer screening: pap smear obtained during the reporting period;

  • Diabetes care: number of glycosylated hemoglobin (HbA1c) tests done in the reporting year along with the most recent result;

  • Hypertension care: blood pressure at the most recent visit or representative blood pressure; and

  • Smoking cessation: documentation that advice on quitting was given.

NMHC patients were deemed most comparable to the Medicaid subgroup within the HEDIS database and that was the point of comparison used by the researchers. NMHC means exceeded the 90th-percentile benchmarks for breast cancer screening (69% for NMHCs vs 60% for HEDIS Medicaid) and blood pressure control (69% for NMHCs vs 66% for HEDIS Medicaid). While the range of quality measures for NMHCs was broad, on most measures, quality measure findings compared favorably to national benchmarks, particularly in the area of chronic disease care management, with some centers substantially above the 90th-percentile benchmarks. The researchers concluded that quality of care across NMHCs was good to very good. Importantly, specific strengths and areas of improvement were identified for each NMHC.

While the majority of NMHCs reporting during the first 3 years were owned by schools of nursing that percentage had decreased to just half by year 4 though this change may simply reflect the characteristics of reporting NMHCs. A relationship with a school of nursing is important, however, because in addition to providing needed healthcare to often vulnerable populations, NMHCs also provide extraordinary learning labs for students, allowing for clinical placements that demonstrate a nursing model of care that allows students to integrate classroom experiences.

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