Improving Access to Primary Care: The Growing Role of Advanced Practice Registered Nurses

Primary care helps Americans live healthier and more productive lives. According to the Institute of Medicine, primary care refers to the work of health care professionals who act as a first point of consultation for all patients. It also includes comprehensive care for the majority of health problems; long-term, person-focused care; and care coordination across providers.0F1
Primary care providers include family physicians, internists, general practitioners, nurse practitioners, and certified nurse-midwives. These clinicians are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Yet, health care consumers face a severe shortage of primary care providers who can care for people of all ages, but particularly those with multiple chronic conditions.1F2 Estimates of the future primary care workforce project a shortage of 35,000 to 44,000 adult primary care providers by 2025.2F3 Moreover, health care reform is likely to provide access for over 30 million more Americans. Advanced practice registered nurses (APRNs), especially nurse practitioners (NPs), as well as certified nurse-midwives (CNMs), are primary care clinicians who increase access to high value primary care and chronic care coordination, particularly in rural and underserved areas of the country. Primary care leaders have advocated for a strong interdisciplinary primary care workforce, 3F4 as reflected in the American College of Physicians’ acknowledgement that NPs are health care professionals who provide important and critical access to primary care.4F5 APRNs: Evidence of Quality Studies demonstrate that, for more than 40 years, consumers have been receiving safe and effective health care from APRNs. In fact, research shows no difference in outcomes of primary care delivered by a nurse practitioner or a physician, including patient health status, number of prescriptions written, return visits requested, or referrals to other providers.5F6 No study establishes a basis for requiring that physicians supervise APRNs. Research also shows the unique aspects of advanced practice nursing by validating that NPs can reduce the number of hospital days for patients,6F7 good news for payers as well as patients and their families; and nurse-led clinics are especially good at prevention.7F8 Research outcomes of obstetrical care provided by certified nurse-midwives include fewer cesarean births and low infant and maternal mortality rates, 8F9which is evidence of high quality and lower costs. The Problem: Restrictive Regulations Threaten Consumer Access to Health Care State Nurse Practice Acts along with related rules and regulations are the laws that define what nurses are permitted to do in caring for patients and their families. This legal permission is known as the “scope of practice” and it is determined by each state. The scope of practice for NPs varies across the United States.9F10 Despite the urgent need to expand access to primary care and preventive services, a number of barriers still prevent consumer access to nurse practitioners in many states.
Who are Advanced Practice Registered Nurses Providing Primary Care?
Nurse Practitioners (NPs) and Certified Nurse-Midwives (CNMs)*provide primary care. NPs and CNMs take health histories, provide complete physical exams, diagnose and treat many common acute and chronic problems, interpret lab results and other diagnostic tests, prescribe medications, and teach and counsel patients and their families about health and illness.
* In addition to the care they provide before, during and after childbirth, CNMs provide primary care services to women from adolescence to late life. Like other APRNs, NPs and CNMs earn at least a master’s degree before become nationally certified.
In some states, nurse practitioners need a written agreement with a physician to diagnose, treat, and prescribe medication. In other states, nurse practitioners practice independently. And some states require physician oversight, referred to as “collaboration,” only for nurse practitioners to write prescriptions. http://championnursing.org/aprnmap
Federal laws and regulations can also be barriers to comprehensive, coordinated primary care including restrictions on admitting patients to hospitals, home health services, and skilled nursing facilities. When NPs are not able to follow their primary care patients to other health care settings, treatments are delayed and costs increase.10F11
Solutions: Modernize Regulations to Increase Access to Care
To ensure Americans have greater access to all qualified health care professionals, we have the following recommendations for state governments:
• Study the experience of those states that have successfully modernized their APRN regulations.
• Modernize nurse practice acts and other relevant state laws to allow APRN independent practice; remove all mandates that APRNs be supervised by a physician; and permit APRNs full prescriptive authority so that they may write prescriptions for all of their patients.
• Revise redundant laws and regulations that require multiple regulatory bodies to oversee APRN practice. There is no evidence that oversight of nursing by boards of medicine contributes to higher quality health care. A state’s Board of Nursing should be the sole regulatory authority of all registered nurses—including APRNs.
The time is now for removing barriers to APRN practice that stand in the way of Americans accessing the high quality, cost effective primary care they deserve.
1 Donaldson Molla, Yordy, Karl, and Neal Vanselow, eds. Defining Primary Care: An Interim Report. Washington, DC: National Academy Press, 1994.
2 Cronenwett, Linda and Victor Dzau. “Co-Chair’s Summary of the Conference.” In Who Will Provide Primary Care and How Will They Be Trained? Edited by Barbara J. Culliton and Sue Russell. New York: Josiah Macy, Jr. Foundation, 2010. http://www.josiahmacyfoundation.org/documents/jmf_ChairSumConf_Jan2010.pdf (accessed March 16 2010).
3 Bodenheimer, Thomas and Hoangmai Pham. “Primary Care: Current Problems and Proposed Solutions.” Health Affairs 29 (2010): 799-805.
4 Josiah Macy, Jr Foundation. "Summary of the Meeting: Developing a Strong Primary Care Workforce." New York: Josiah Macy, Jr Foundation, April 2009. http://www.macyfoundation.org/documents/jmf_primarycare_summary.pdf (accessed March 16, 2010).
5 American College of Physicians. Nurse Practitioners in Primary Care. Philadelphia: American College of Physician, 2009.
6 Horricks, Sue, Elizabeth Anderson, and Chris Salisbury. “Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors.” British Medical Journal 324 (2002): 819-823.
7 Lenz, Elizabeth R., Mary O’Neil Mundinger, Robert L. Kane, Sarah C. Hopkins, and Susan X. Lin. “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: Two-year Follow-up.” Medical Care Research and Review 61 (2004): 332-351.
8 Raftery, James P., Guiqing L. Yao, Peter Murchie, Neil C. Campbell, and Lewis D Ritchie. “Cost Effectiveness of Nurse Led Secondary Prevention Clinics for Coronary Heart Disease in Primary Care.” British Medical Journal 330 (2005): 707-710.
9 Raisler, Jeanne. “Midwifery Care Research: What Questions Are Being Asked? What Lessons Have Been Learned?” Journal of Midwifery & Women’s Health 45, no. 1 (January/February 2000): 20-36.
10 Hudspeth, Randall. “Finding Answers.” Advance for Nurse Practitioners (March 26, 2009), http://nurse-practitioners.advanceweb.com/Editorial/Content/Editorial.aspx?CTIID=2698&RPID=34&RPID=13.
11 Sherwood, Gwen, Mary Brown, Vaunett Fay, and Diane Wardell, “Defining Nurse Practitioner Scope of Practice: Expanding Primary Care Services.” The Internet Journal of Advanced Nursing Practice 1, no. 2, (1997), http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol1n2/scope.xml.