It's been more than a decade since nurse-led managed care and clinics were advanced as part of the Affordable Care Act. But the pandemic shifted that effort into overdrive with the expanding role of nurses and nurse practitioners (NPs) in managing public health, including administering vaccines and caring for vulnerable, marginalized, and underserved populations.
Nearly half of all states have adopted full practice authority legislation, streamlining healthcare delivery by granting NPs the ability to provide comprehensive services without oversight from physicians. And most other states during the pandemic have either temporarily suspended or waived requirements that limit NPs' ability to provide immediate care. That number is on the rise as a result of the staggering demands of the pandemic, according to the nursing sources Medscape Medical News consulted.
At the beginning of the pandemic, the need for NPs to practice to the full extent of their training and education and without regulatory burdens became clear with rising primary care caseloads, said Kristine Gonnella, senior director of strategic initiatives for the National Nurse-Led Care Consortium (NNCC). The smaller communities faced the largest burden, especially if they also had doctor shortages, she said.
"It accelerated innovation as a result of that," Gonnella said. "People had to take a hard look at policy and [allow the full] practice authority of nurse practitioners. A lot of policy impacting nurse practitioners is state-based."
As of press time, a total of 24 states, the District of Columbia, and two US territories have given NPs full practice authority. The latest two states were Massachusetts and Delaware. As part of the state of emergency responses to the pandemic, 21 other states relieved some component of practice authority restrictions and six states are holdouts, according to April Kapu, DNP, APRN, president of the American Association of Nurse Practitioners.
The main benefit of full-practice authority is easier access to care, "particularly in underserved communities," Kapu said. "Patients were able to get the care in areas known as provider shortage areas." According to the Health Resources and Services Administration (HRSA), 85 million Americans lack access to primary care in shortage areas. Those areas need to more than double the number of health professionals serving them, the HRSA reported in early November.
NPs, along with physician assistants (PAs) — also permitted to practice more fully during the pandemic in some states — are needed to step in and replace a growing number of retiring primary care doctors, according to a new report by Mercer on the healthcare market.
Those in favor of giving NPs greater authority claim it eases access to care at a time when it is most critical, improves healthcare outcomes, reduces healthcare disparities, and increases health equity. But not everyone agrees.
Physician Groups Fight Change
The California Medical Association, arguing against greater authority for NPs, said in a statement last year, "We strongly believe that physician-based care is the model that ensures the greatest patient safety and highest quality care for all Californians, regardless of income."
And the Wisconsin Academy of Family Physicians (WAFP) more recently questioned the education and training of nurses compared with doctors and would rather see collaboration agreements between doctors and nurses working "together to consult and strategize the best course of treatment for patients," according to a statement.
WAFP executive director Larry Pheifer said the organization has a good relationship with the state's nursing organization and believes in team-based care. "There are significant physician training and educational differences that should support continuation of the collaborative agreements," he told Medscape. Wisconsin is under an executive order that temporarily suspends practice agreements.
Sabrina Hofmeister, DO, is co-chair of the WAFP legislative committee and has been a family physician for 10 years. She reiterated the WAFP opposition to advanced practice registered nurses (APRNs) practicing independently and the extension of the waiver as a permanent solution. Hofmeister said not enough research and analysis was done to prove that such an arrangement would be "in patients' best interests. ...We feel patients are entitled to be under the care of a physician and while APRNs are valuable, the care that's best is under a physician" or through collaboration, she said.
Hofmeister cited the 15,000-18,000 hours of residency training doctors undergo compared with the 500-1500 hours for APRNs.
She said proponents of advanced scope of practice for nurses claim that it improves access to care for rural locations, but "a low percentage of individuals work in those areas. ...Over 80% are in urban areas, so that claim is false."
Furthermore, the WAFP believes that nurses practicing independently will lead to an "increase in prescribing of antibiotics and opioids and an increase in ordering of diagnostic testing — overall a drain on the healthcare system."
In her own practice, Hofmeister works with NPs. "I value their care. We work collaboratively. That practice arrangement works very well. It's the independent practice arrangement that I am and we are concerned about."
California temporarily waived select practice agreements, such as the limitations on the number of NPs a doctor or surgeon is authorized to supervise at a time for furnishing or ordering drugs or devices.
"Those with a larger physician lobby effort have been harder to realize full practice authority," the NNCC's Gonnella told Medscape.
Evolving Role of Nurses
Meanwhile, the role of the NP has been evolving since their licensing and certification was first regulated in the 1970s, and the role continued to expand to meet the demands for increased access to care as a result of the Patient Protection and Affordable Care Act.
The Affordable Care Act was the first law to officially define nurse-managed health centers, specifically a "nurse-practice arrangement, managed by advance practice nurses, that provides primary care of wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency."
The federal health reform law also established a grant program to offset the costs of operating these clinics, which provide comprehensive medical services "without regard to income or insurance status of the patient for the duration of the grant period." To start $50 million was allocated toward developing nurse-led clinics and training. So far, $15 million has been used, Kapu said. "That was really helpful to set up practices."
Having a viable funding source and diversified financial support was the key to the success of such programs, Gonnella said.
Nurse-managed health centers relied on an array of funding. For many of the clinics, becoming a federally qualified health center (FQHC) offered access to foundational funding, she said. But not all of the clinics are FQHCs, noted Sarah Hexem Hubbard, NNCC executive director.
Gonnella said that nurse managed health clinics had the FQHC network along with foundational funding and a reimbursement mechanism. "Independent practices don't have that backbone and support," she said. "Especially with the care like [that] provided during COVID, that could make them more vulnerable.
"Nurse-managed health clinics were better able to sustain themselves if they were affiliated with a health and hospital system," Gonnella continued. "If they were running clinics not with institutionally supported funding and support, it was difficult to sustain their work. A couple of clinics [across the country] closed during the pandemic if they didn't have the funding mechanism and institutional support. Conversely, federally supported nurse-care models of care continued to grow and thrive."
At last count, there were more than 250 nurse-led clinics nationwide, according to the NNCC.
The Effects of COVID on Nursing
During the pandemic, nurses were the frontline workers in vaccinations efforts, with public health nurses and home care nurses working with health departments to ensure each vial of vaccine was used to its full potential, Gonnella explained.
Kapu also believes that the state COVID emergency waivers provided "an opportunity for NPs to demonstrate they could provide excellent care and care to the best of their education and training" along with increased access to care. "My hope is that, because of the executive order, we will see more states move toward full practice authority."
The pandemic not only created expanded opportunities for nurses, it also highlighted their importance as part of a coordinated healthcare delivery team, which includes PAs and physicians, Gonnella said. "If a lesson was learned [during the pandemic], it was the importance of partnerships. ...We recognize who our partners are in healthcare. It was an opportunity to provide more coordinated care and recognize and engage those partners, because we can't do that alone.
"We are not advocating that nurse-led care is the only model of care," Gonnella said. "When the ability is there for a care-team model, a coordinated approach to provide care, the optimal [scenario] is a care team where everyone understands their role." That includes nurses, physicians, medical assistants, care coordinators, patients, and patients' families. "When that exists, it's very powerful."
Gonnella understands there will be skeptics to changing the historically accepted physician hierarchy. "In any innovation, when you challenge a model of care, there's going to be inherent concerns." She adds, "There needs to be buy-in within systems of what's best for patient care. That takes time."
She acknowledged the reforms that have already taken place. "It's been a historic evolution in which the role of the NP [is now better understood] within the medical community. ...It's a very fluid environment," she concluded. "It remains to be seen, the impact of COVID."
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Image 1: National Nurse-Led Care Consortium
Image 2: American Association of Nurse Practitioners
Image 3: National Nurse-Led Care Consortium
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Cite this: With More Freedom, A Nurse-Led Model for Healthcare is Gaining Ground During Pandemic - Medscape - Nov 11, 2021.