Nurse Practitioner Based Primary Care Clinics: A viable solution to the shortage of health care providers.

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1 Nurse Practitioner Based Primary Care Clinics: A viable solution to the shortage of health care providers. Dr. Tony Hilton & Dr. Meliissa Mahabee DrPH, MSN, FNP. Medical Director NAFC Annual Conference October, 2014 Kansas City, MO

2 Objectives * Discuss how Advanced Practice Nurses are a critical key to partnering with community stakeholders in filling gaps to health care services. * We will discuss how a Nurse Practitioner can utilize principles to start a private practice to service the uninsured by providing free or low cost medical care. * We will explore how to partner with schools of nursing by integrating faculty and student practice as an additional component to service longevity. * We will give several examples and case studies of how to develop a clinic from concept to practice as well as common barriers, opportunities and some possible management approaches.

3 Background * The Association of American Medical College predicts that the country will have 63,000 too few doctors as soon as 2015 * AANP plans through advertisements, public service announcements and events, the organization will try to raise the profile of the country s 155,000 nurse practitioners. * In 17 states, nurse practitioners can practice without the supervision of another professional such as a doctor. * In fact, 75 percent of the 157,000 credentialed nurse practitioners in the U.S. provide primary care, according to the American Association of Nurse Practitioners (AANP) * There are over 450 nurse practitioner schools of nursing

4 * Full Practice: State practice and licensure law provides for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments including prescribe medications under the exclusive licensure authority of the state board of nursing. This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing. * Reduced Practice: State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care. * Restricted Practice: State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team- management by an outside health discipline in order for the NP to provide patient care * AANP

5 How to get started * Identify your: * Goals and objectives * Mission Statement * Vision Statement * Complete a community assessment

6 Community Assessment What is your marital status? Single 5% Married 81% Divorced 14% Doctorate Degree Masters Degree 2% 3% Batchelors Degree 12% What is your level of education? Not Selected 11% Some Highschool 39% Do you have insurance? No 41% Some College 13% What is your race? Caucasian 2% Highschool Diploma 20% Yes 59% Hispanic/ Latino 98%

7 Community Assessment What is your primary language? English 19% What is your household size? Six 11% Seven 2% Ten 4% One 4% Two 18% Spanish 81% Five 24% Four 31% Three 6% Do you have a family doctor? Yes 62% No 38% Where did you receive care last year? Other 3% Specialist's Office 6% None 29% San Bernardino County Health 7% Family Doctor's Office/Health Clinic 45% Hospital Emergency Room 10%

8 Community Assessment Do you have prescription coverage? Yes 57% No 43% Can you afford your prescription? Yes 57% No 43% Did you go to the ER because you had no family doctor? Yes 14% No 86% Was your child immunized? Yes 97% No 3%

9 Community Assessment Did your child have a well- child check? Yes 94% No 6% 3 Why I did not see a family doctor? 5 0 Count What Medical Conditions do I have? Count What Medical Conditions do I have? Count

10 Community Assessment % % % % Age Range % % % % % Are you employed? Yes 55% No 42% Not Selected 3% What is your monthly Income? What is your gender? Above % % % % Male 41% Female 59% %

11 Education or training that I might be interested in? Count

12 Who are you? * Mission: The Mission of Health Center is: * To continue the healing ministry of Jesus Christ by providing access to health care and wellness services to all ages in the Yucaipa Valley community * Vision: The Vision of Health Center is: * To provide the opportunity for the uninsured and underinsured person in our service area to receive preventive care and early treatment; * To increase access to healthcare and wellness services across the life span thereby reducing disparities; * To give to the people the opportunity of enriching their lives with the knowledge of the gospel of Jesus Christ.

13 Board Development * A good board is a victory, not a gift * Cyril O. Houle, Governing Boards

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15 Start up management Tools

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17

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19 OPERATION: Restore Health Care Access * Welcome to Redlands Community Hospital. * We are a 172- bed facility located in Southern California, mid- way between Los Angeles and Palm Springs. We've been providing quality healthcare to our neighbors in Redlands and surrounding communities since With over 250 board certified physicians and more than 100 health plans, many of our Inland Empire neighbors rely on us for all their healthcare needs.

20 Service Area

21 Hospital Based Clinic * We provide Healthcare the Way it Should Be * Personal. * Caring. * Comprehensive * Accessible.

22 Who we are * Purpose: * Our primary purpose is to provide low- cost quality health care in an environment that enables people to take personal responsibility for their health * Vision * To provide the opportunity for every uninsured and underinsured person to receive preventive care and early treatment * To increase access to health and reduce disparity * Develop increased access, depth and quality services * To provide a full spectrum of services across the life span * To offer and determine eligibility of public assistance programs

23 Our mission * To provide low- cost/no- cost family based health services to persons who do not have access to care * To respect the dignity and autonomy of each person by supporting them to participate in their health care decisions * To serve as a role model as a health care organization to promote advocacy, teamwork and shared decision- making.

24 Our Goal * To provide primary health care services to people who do not otherwise have access because of: * Financial * Cultural * Language * Lifestyle * Psychological barriers

25 Objectives: To provide no- cost family based health services to persons who do not have access to care: Comprehensive health care screening; Preventive health services; Uncomplicated sick visits; Referrals to specialty care; Referrals to ED/acute care. To respect the dignity and autonomy of each person by supporting them to participate in their health care decisions; To serve as a role model as a health care organization to promote advocacy, teamwork and shared decision- making; To facilitate referrals and access to public assistance, primary and specialty care programs

26 Community Partnerships * Redlands Unified School District * Yucaipa Unified School District * Building a Generation * Redlands Yucaipa Guidance Clinic * United Way * Health Net Healthy Families * Biodata Laboratories * West Coast Imaging * Loma Linda University School of Dentistry

27 Yucaipa Family Clinic

28 Clinical Team * Supervising Family Practice MD/Medical Director * Clinical Director * Family Practice Nurse Practitioner/Clinic Supervisor * Front office clerk/ma * Back office MA * Patient Account representative

29 Phases of Development * Phase II * Uncomplicated pediatric sick visits * Adult school/work physicals * Uncomplicated adult sick visits * Immunizations for all ages * TB screening for all ages * Community Flu vaccine administration * Community Health Fairs

30 Program Development * Phase III * Primary Care services for all ages * Comprehensive health care screening * Comprehensive preventive maintenance * Comprehensive uncomplicated sick visits * Comprehensive complicated sick visits * Referral to specialty care services * Referral to ED/acute care admissions

31 Summary and Recommendations * A hospital based clinic presents an excellent model to support care for the uninsured and underinsured population in the surrounding community. * NP model of based family practice care is a viable option to service the underserved communities * Clinical leadership and management staff who are trained to develop community based programs can be successful in implementing their vision * Clinical staff should understand the culture of poverty as well as demonstrate cultural sensitive care.

32 Evaluation Methods * Number of new patients/month per site * Quality performance/ improvement management * Patient satisfaction surveys * Clinical Outcomes reporting * Regulatory/surveyor onsite reviews * Total of free care/low cost care in dollars reported * Number of participants attending community education programs * Number of participants at community health screenings * Number of new clinical programs added

33 Once upon a time The story of H Street Clinic: The Past, Today and the Future by Tony Hilton Annie Hilton

34 Central City Lutheran Mission Staff had a splendid Idea A Community Clinic!!

35 Then they got to work at building H Street Clinic This is how it all began!!

36 The Year 1996 * Needs assessment of the community done by Dept of Social Work at Cal State SB * Three priorities identified * Education needs for children * Community Health Care * Housing for low income families

37 The year 1998 * A very sad time of loss of Isaac who died of a seizure. * This wake up call brought a vision of health care services. * Questions surfaced were * Where would this be built * How will it operate * Where would the money come from

38 * Partnerships were formed between * CaL State SB * Central City Lutheran Mission * Loma Linda University School of Public Health * Funding opportunities explored The Year 2004

39 The Year * CCLM purchased property to build H Street Clinic * The area was rezoned to provide a permit for a health clinic and recreational building. * A conditional use permit was issued to build the clinic

40 The Year * It took 2 years to obtain funding to build the 6100 sq ft, 2.5 million dollar clinic. * Then the bulldozing began.

41 * Building the dream * Ground breaking * Starting the building * Completion of structure * Open house dedication The year 2004

42 Health Fairs and Community Screenings

43 * The Fox Group was invited to participate in: * Feasibility Study * Program Planning * Program Implementation * Long-term Consulting The Year 2005

44 The Year 2007 * Funding received to open clinic. Initial Donors included: * San Manuel Band of Mission Indians * CHW/Saint Bernadine Medical Center Foundation * Weingart Foundation Staff hired Equipment and supplies set up Open house celebration Media Coverage Primary Care Services Started

45 The present

46 * Manager * NP * Front Office * Back Office * Patient Account Representative Medical Director H Street Clinic Staff

47 Open House News

48 Open House Health Fair Celebration

49 The Dream: Now A Reality * The Goal: * To provide primary health care services to vulnerable people who do not otherwise have access because of: o Financial o Cultural o Language o Lifestyle, or o Psychological barriers

50 The Dream: Now A Reality * The Vision * To provide the opportunity for every uninsured and underinsured person to receive preventive care and early treatment

51 The Dream: Now A Reality Mission * To provide low-cost/no-cost family based health services to persons who do not have access to care. * To respect the dignity and autonomy of each person by supporting them to participate in their health care decisions.

52 The Year 2008 and Beyond * Goals and objectives * Licensing and Certification * MediCal Specialty programs * Medicare and other third party payors * Medial Specialty Services * Pharmaceutical products * Radiological Services * Education & Preventive Care Programs * Urgent Care Services * Extended hours for primary care services * And much more

53 Minor Surgery

54 Colposcopy and Anoscopy Services

55 The Future: Radiology Services

56 The Future: Urgent Care Services

57 Lessons Learned * Every community is different. * Every clinic can be similar * Identify Key Players and supporters in the community * Identify Schools of Nursing who offer Nurse Practitioner programs * Connect with a mentor who has started a NP model based practice * Sustain a quality improvement program * NURSE PRACTITIONER BASED PRACTICE CAN BE A VIABLE SOLUTION TO FREE AND CHARITABLE CLINICS!

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