Expanded roles of registered nurses in primary care delivery of the future

Registered nurses in primary care: A value proposition

Who is responsible for what tasks within primary care: Perceived task allocation among primary care providers and interdisciplinary team members

To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes. 2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims. We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models. An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p<.05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p<.05). Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.

To address the prevalence of chronic diseases in Newfoundland and Labrador, the province has committed to primary health care reform, including implementing interdisciplinary primary care (PC) teams. To inform discussions regarding integrating nurse practitioners (NPs), registered nurses (RNs), and licensed practical nurses (LPNs) into these teams, better understanding of their roles in PC is needed. A scoping review was conducted to examine and synthesize existing evidence related to nursing roles and resources in PC settings across Atlantic Canada (Newfoundland and Labrador, New Brunswick, Nova Scotia, Prince Edward Island), and associated contributions to patient care. Joanna Briggs Institute scoping review methodology was used. The Nursing Role Effectiveness Model guided the review. Twenty articles met inclusion criteria. Roles of RNs and NPs in PC included chronic disease management, education, and health promotion. No literature focused on LPNs. Interdisciplinary collaboration was evident across studies. However, nurses’ functions within teams were limited by institutional constraints and other providers. PC settings with nurses had positive clinical outcomes, improved access to services, and high patient satisfaction. The prevalence of nursing in PC throughout Atlantic Canada and how nurses’ roles are enacted is unclear. There is opportunity for future inquiry into specific attributes of nursing and PC teams that result in positive patient and system outcomes.

Primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained relationship with patients, and practicing in the context of family and community. 1 A frontline, broad based and holistic approach makes primary care essential for the success and sustainability of any healthcare system. In most circumstances, Family Physicians, Internists, Pediatricians and Obstetricians form the core Primary Care Practitioners. Family Physicians form the main component of the primary care team. Scandinavian countries have better health indicators in Europe because of strong emphasis given to primary care. South India has better health indicators compared to rest of India, again because of the presence of primary care orientation to health care delivery. Similarly, Sri Lanka has better health indicators in the region because of their strong emphasis on primary care. There is enough evidence to suggest relationship, better health indicators and primary care orientation of health care delivery.2 Ten industrialized countries were compared on the basis of the extent of primary health service, twelve health indicators and population satisfaction with overall costs of the systems. A general concordance was found among these three characteristics, highlighting the importance of primary healthcare, health indicators and the costs of health care.3 In today’s, day and age with rising cost of health care, a primary care orientation of health care is the way forward. The role of primary care in ensuring success of health care delivery is critical for several reasons. The frontline position allows Primary Care Practitioners to offer preventive care and health maintenance initiatives to their patients and diagnose diseases in early stages where they can be successfully handled with minimum and cost effective interventions. The community based location of Primary Care Practitioners offer them a unique position to provide care to patients in their context and environment. Patients are known to their practitioners, allowing a better understanding of their symptoms. The trusting relationship exists between a Primary Care Practitioner and patients, allowing better sharing of information and with confidence. The Primary Care Practitioner knows their patient’s health seeking behaviour, allowing them to determine appropriate approach for their symptoms evaluation. They also know their patient’s family which allows better understanding of home dynamics and its impact on health. The role of family in the health care of individual patient can be exploited to get better health outcomes. The community based location of Primary Care Practitioners allow them to be the main focus for patient care and referrals. The ‘gate keeper’4 position of Primary Care Practitioner in selecting patients for hospital care referral curtails health care costs. Primary Care Practitioners are trained in effective communication skills, which allow them to better communicate and understand their patient’s problems. Practice of effective communication skills is known to improve patient’s satisfaction with the clinician.5 These skills allow Primary Care Practitioner to form the focus for effective communications between patient and the health care team, supporting other members of the team in delivery of this challenging task. Primary Care Practitioners practice holistic medicine, allowing them to effectively handle multiple patient problems at the same time. The bio-psycho-sociospiritual model of medical practice allow them to tackle patient complaints at multiple levels. This provides value to them in the health care delivery by providing cost effective care in a convenient manner and leads to enhanced patient’s satisfaction.

BackgroundTeam-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care.MethodsAs part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices.ResultsLEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs), and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently.ConclusionsThe 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform.

IntroductionMany medical schools overestimate the percentage of their graduates who enter the primary care workforce based on the “first-certificate” residency their graduates enter. To rectify this problem, Deutchman and colleagues proposed a new method of estimation. The objective of this study was to compare results from the traditional residency match and Deutchman methods to the actual percentage of University of Kansas School of Medicine (KUSM) graduates who practice primary care after completing medical school and all residency and subspeciality fellowship training.MethodsA retrospective study was conducted using a convenience sample of KUSM graduates from 2003–2014. Percentages of graduates classified as primary care by the traditional Residency Match Primary Care Method (RMPCM) and the percentages of graduates identified as primary care by Deutchman’s Intent to Practice Primary Care Method (IPPCM) were compared with the actual percentage of graduates who eventually entered the primary care workforce.ResultsOf the 1,944 KUSM graduates identified during the study period, the RMPCM predicted a 48.1% primary care output rate. The Deutchman’s IPPCM predicted a 22.8% primary care output rate. The actual known percentage of graduates practicing primary care was 34.2%.ConclusionsNeither the RMPCM nor the Deutchman’s IPPCM performed well in predicting the percentage or number of KUSM graduates who eventually practiced primary care. Due to predictions for the shortage of primary care physicians, there is a need to identify a method that more accurately predicts the medical schools’ contribution to the primary care workforce.

FigureFigureUnlike other health professionals, physician assistants have the unique capability to change specialties over the course of their careers (usually without additional formal training), a characteristic that provides advantages both to them and to employers. Such clinical flexibility permits PAs to adapt relatively quickly to changing workforce needs and emerging medical practice niches. The bedrock for this capability is the PA's foundation of general medicine and close practice relationship with physicians. The specific dimensions and patterns of PA career flexibility have been quantified, and their mobility is distinct. An analysis of AAPA data containing 42 annual cohorts of PA graduates documented patterns of specialty change.1 Among the findings, Half of clinically active PAs changed specialties sometime in their careers; One-quarter practiced in at least two different specialties; 11% have worked in three or more specialties; Since the late 1990s, the net number of PAs departing family medicine has exceeded the number entering it; Some PAs move from medical and surgical specialties to family medicine. That PAs exercise their option to change specialties over the course of their careers is important on several levels. On an individual level, clinical flexibility is a distinct advantage in the modern medical marketplace, permitting movement vertically as well as horizontally within medical practices as well as to pursue opportunities in emerging fields. PAs display considerable movement among the various clinical specialties, and presumably, they use flexibility in advancing their professional careers or make adjustments to accommodate social dynamics. Analysis of market trends suggests that PAs respond to opportunities where they can optimize their income and that this often means employment changes within and across specialties.2 The PA sees an abundant job reservoir and makes choices based on factors such as location, salary, specialty of interest, and others. Along the career path, the PA may shift focus based on availability and income: popular choices today for PAs include emergency medicine, dermatology, orthopedics, cardiovascular medicine, and interventional radiology. On a policy level, clinical flexibility holds potential for PAs to address critical health workforce needs in a timely manner. Health workforce policy experts are seeking ways to recruit providers to primary care, and PAs who can change specialties offer the potential for a near-term boost to the supply of primary care providers. In addition, hospitals, large managed care organizations, the Department of Defense, the Veterans Health Administration, and other institutions have utilized the career flexibility characteristics of PAs for decades. One hospital in Baltimore employs more than 60 PAs for many interspecialty roles within the institution, as they are sometimes called to work in emergency medicine, on the wards, or in the theater when shortages emerge. This makes the PA highly utilitarian. The underpinning of general medicine that PAs are grounded in permits them to change specialty roles without having to undergo formal retraining. Entering PA students also highly value the ability to change specialties. While applicant or student appreciation of clinical flexibility has not been formally quantified, it is believed to be a key factor in career selection in the health professions applicant pool. An additional implication of the finding of broad and frequent specialty change by PAs has to do with the potential threat to clinical flexibility from the emergence of PA specialty certification examinations. Should such examinations become well-established and valued by PA employers, this could pose barriers to the entry of PAs into certain clinical specialties. One health workforce policy approach that could take advantage of PA clinical flexibility in efforts to augment America's primary care workforce is to develop incentives aimed at attracting new graduates, as well as enticing journeyman PAs, to enter (or re-enter) primary care. Such strategies could bear fruit in a shorter period of time than producing increased numbers of primary care physicians. Tax benefits, education loan repayment, and relocation expenses are tested and effective measures to produce this type of movement. Those PAs trained in the uniformed services could be transitioned to civilian roles, coupled with settlement enhancements and tax incentives. Their skills would be highly valued in rural and medically underserved areas. The creators of what was then called the new health professional intended the American PA to be flexible and contributory in all aspects of medicine.3 For them, a dynamic, flexible clinician who differed from a doctor was a concept to be promoted. The PA of the new century seems to have lived up to that measure.

An ageing population with an increasing prevalence of chronic disease and complex medication regimens has placed a strain on healthcare systems in Canada. A limited number of team-based primary care pharmacists are integrated into primary care clinics across the country, working alongside other members of the health care team to identify and resolve drug therapy problems and improve outcomes. While many studies have been completed in the area, the extent of research on integrated team-based primary care pharmacists in Canada is unknown. The objectives of this work were to describe the literature that exists surrounding pharmacists in a primary health care team setting in Canada. A scoping review of research focusing on pharmacists in team-based primary health care settings in Canada was performed. Thematic analysis was then performed to categorize the identified studies. The search identified 874 articles, of which 93 met inclusion criteria relevant to the objective. From these 93 studies, 4 themes and 23 subthemes were identified, with some studies having more than one theme or subtheme. Themes identified were the following: primary care pharmacist scope of practice (n = 79 studies), collaboration/communication within the primary care setting (n = 26), chronic disease management (n = 24) and 'other' (n = 15). This research quantified and categorized 93 studies on pharmacists in interprofessional primary care teams in Canada. As this is an expanding role for pharmacists in Canada, understanding the current state of the literature is an important consideration when developing future team-based primary care roles.

BackgroundThe PR1MaC study was conducted to evaluate the integration of Chronic Disease Prevention and Management services into primary care practices and was reported effective. The aim of this study was to further explore the effects of the PR1MaC intervention on patients and their family.MethodsWe conducted a qualitative study embedded in a randomized controlled trial. The trial was implemented in eight primary health care practices in the Saguenay region, Quebec, Canada. The interdisciplinary patient-centred team-based intervention included self-management support and a motivational approach. We conducted focus groups and semi-directed individual interviews with patients, family members and healthcare professionals.ResultsPerceived positive effects can be grouped into six major themes: awareness, improved knowledge, improved motivation and empowerment, adoption of healthy behaviours, improvement of health status and improvement of quality of life. On the negative side, some participants reported lack of sustainability of newly acquired benefits in the months following the intervention.ConclusionsIntegrating chronic disease prevention and management services into primary care settings had impacts on patients and their family members. These findings are consistent with findings that were reported in the quantitative study. Further studies should address longterm sustainabilility in terms of benefits for the patients.Trial registrationClinicalTrials.gov, no.: NCT01319656.

Medicare annual wellness visits (AWVs) are prevention-focused healthcare visits free to Medicare recipients. These visits focus on health maintenance, health risk assessment, prevention of illness, and maintaining independence, all of which are within the scope of registered nurse (RN) practice as well as aligned with what matters, medication, mentation, and mobility - the 4Ms - of age-friendly health care. The objective of this pilot study was to evaluate the implementation of the 4Ms in the context of RN-led Medicare AWVs in a primary care practice. In a primary care practice with approximately 2500 patients, including approximately 571 of whom were enrolled in Medicare, RN-led Medicare AWVs were implemented, incorporating the 4Ms framework. During this time, data were collected on the effect of the AWV on access to care-conceptualized here as the number of visits available as well as the type of clinician open to staff these visits. Data collection also included patient responses to the 4Ms question "what matters most?" Overall, the RN-led visits were successful and beneficial to the practice. Each RN-led visit allowed for 2 additional acute or monitoring visits per provider (nurse practitioner, MD) per day, increasing patient access to their primary care providers. Inclusion of the 4Ms questions facilitated discussion around overall mental and emotional well-being, life stressors, quality of life, and goals of care. RN-led Medicare AWVs incorporating the 4Ms framework enhances the role of RNs in primary care by focusing on a health promotion role, utilizing RNs to their full scope of practice. RN-led AWVs increase provider availability for acute and chronic care appointments, as well as foster conversations around quality of life, as well as mental and emotional well-being.

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

Burnout negatively affects physician health, productivity, and patient care. Its prevalence is high among physicians, especially those in primary care, yet few qualitative studies of burnout have been performed that engage frontline primary care practitioners (PCPs) for their perspectives. To identify factors contributing to burnout and low professional fulfillment, as well as potential solutions, by eliciting the views of PCPs. For this qualitative study, focus group discussions and interviews were conducted between February 1 and April 30, 2018, among 26 PCPs (physicians, nurse practitioners, and physician assistants) at a US academic medical center with a network of 15 primary care clinics. Participants were asked about factors contributing to burnout and barriers to professional fulfillment as well as potential solutions related to workplace culture and efficiency, work-life balance, and resilience. Perceptions of the factors contributing to burnout and low professional fulfillment as well as potential solutions. A total of 26 PCPs (21 physicians, 3 nurse practitioners, and 2 physician assistants; 21 [81%] women) from 10 primary care clinics participated. They had a mean (SD) of 19.4 (9.5) years of clinical experience. Six common themes emerged from PCPs' experiences with burnout: 3 external contributing factors and 3 internal manifestations. Participants described their workloads as excessively heavy, increasingly involving less "doctor" work and more "office" work, and reflecting unreasonable expectations. They felt demoralized by work conditions, undervalued by local institutions and the health care system, and conflicted in their daily work. Participants conveyed a sense of professional dissonance, or discomfort from working in a system that seems to hold values counter to their values as clinicians. They suggested potential solutions clustered around 8 themes: managing the workload, caring for PCPs as multidimensional human beings, disconnecting from work, recalibrating expectations and reimbursement levels, promoting PCPs' voice, supporting professionalism, fostering community, and advocating reforms beyond the institution. In sharing their perspectives on factors contributing to burnout, frontline PCPs interviewed during this study described dissonance between their professional values and the realities of primary care practice, an authority-responsibility mismatch, and a sense of undervaluation. Practitioners also identified possible solutions institutions might consider investing in to resolve professional dissonance, reduce burnout rates, and improve professional fulfillment.

BackgroundIn this review study, we are the first to explore whether the practice nurse (PN) can act as case manager lifestyle counselling regarding weight management in primary care.MethodsMultiple electronic databases (MEDLINE, PsycINFO) were searched to identify relevant literature after 1995. Forty-five studies fulfilled the inclusion criteria. In addition, all studies were judged on ten quality criteria by two independent reviewers.ResultsEspecially in the last three years, many studies have been published. The majority of the studies were positive about PNs’ actual role in primary care. However, several studies dealt with competency issues, including disagreement on respective roles. Thirteen studies were perceived as high quality. Only few studies had a representative sample. PNs’ role in chronic disease management is spreading increasingly into lifestyle counselling. Although PNs have more time to provide lifestyle counselling than general practitioners (GPs), lack of time still remains a barrier. In some countries, PNs were rather ambiguous about their role, and they did not agree with GPs on this.ConclusionThe PN can play the role of case manager lifestyle counselling regarding weight management in primary care in the UK, and wherever PNs are working under supervision of a GP and a primary health care team is already developed with agreement on roles. In countries in which a primary health care team is still in development and there is no agreement on respective roles, such as the USA, it is still the question whether the PN can play the case manager role.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-014-0197-2) contains supplementary material, which is available to authorized users.

Registered nurses (RNs) in Ontario have been asked to work collaboratively with family physicians (FPs) and other healthcare professionals in the family practice setting to improve the efficiency and effectiveness of healthcare delivery (OFPN 2005). Yet, little is known about the optimal utilization of the RN's role in family practice. This study builds on recent conversations regarding utilization of the nursing workforce (Oelke et al. 2008) and the nursing role (White et al. 2008) in the acute care setting by presenting perceptions of the role of the RN in an urban academic family practice setting. Interviews were conducted with 23 healthcare professionals of varying disciplines across three interprofessional academic family practice units in a Canadian city. Interviewees were asked about their perception of the RN's role as it relates to interprofessional collaboration (IPC). Our findings suggest that ambiguity surrounds the RN's role in family practice in general and in IPC in particular. Also, an FP's level of trust in an RN was found to be a central theme and an important variable in determining FP-RN collaboration, with higher levels of RN trustworthiness associated with higher levels of FP-RN collaboration. Optimal utilization of the family practice RN requires leadership in clarifying the RN's role in IPC, and why and how trust among IPC members is cultivated and nurtured.