Richard Rieselbach, MD, published online an abbreviated version of "Neighborhood Clinics Are a Key Component of a New MEGA Community Health Center Paradigm." Below is the full text of the article authored by Aaron Friedman, MD; Richard Rieselbach, MD; Greg Nycz, BS; Eleanor McConnell, PhD, RN; Nancy Short, DrPH, MBA, RN; Katherine Pereira, DNP, FNP-BC; and Kenneth Schmader, MD.

Introduction

            Neighborhood Community Health Center (CHC) clinics located in underserved urban areas or rural communities are a key component of the new MEGA CHC paradigm described in the accompanying posts (1,2).  Nurse practitioners (NPs) would serve as the primary care professional (PCP) leading a local neighborhood team in collaborative practice, coordinating care with the central CHC, extensively using the electronic health record (EHR).

            The proposed MEGA Teaching Health Center (THC) demonstration (2) would serve to develop this model, with an interprofessional education curriculum for both NP and primary care physician (MD) trainees designed to implement a primary care model that emphasizes collaboration and addresses social determinants of health.  In this post we describe 1) the logistics of the proposed collaborations in practice, emphasizing the importance of EHRs, 2) the administration of the care team and the neighborhood clinics, 3) the necessary interprofessional educational curriculum, 4) financial support for neighborhood clinic NP faculty and trainees, and 5) advantages of MEGA THC neighborhood care for lower-income, vulnerable Medicare patients.

The Logistics of Proposed Collaborative Practice

            Primary healthcare delivered by well-functioning teams leads to better access and patient outcomes, efficiency and greater patient and provider satisfaction (3).  Developing neighborhood clinics utilizing a collaborative practice model could enable CHC expansion in the face of a primary care physician shortage, and could facilitate expansion of some of our 1,200 CHCs to better address social determinants of health and access challenges, as proposed in an accompanying post (2). An essential element of team function is collaborative practice (CP), defined as multiple health-related workers of different professional backgrounds working together with patients, families, caregivers and communities to deliver the highest quality of care (4).

           The Patient Centered Medical Home (PCMH) is an approach to team care delivery that has demonstrated improved patient experience and population health, and reduced cost of care.  The evolving PCMH model utilizes team-based care with clinicians and staff working at the top of their skill set (3).  The neighborhood-based patient care model could enhance the PCMH by its extension into neighborhoods and communities where patients live.  Compared to the usual visit in a large CHC clinic, team care in these settings could better facilitate many components of care, such as health education, screening and awareness of social determinants impacting health.  This neighborhood approach to comprehensive primary care could be located in urban public housing developments or in small rural community clinics.  The EHR of each patient would serve to coordinate their care across disciplines and with the central CHC in that region.

            Neighborhood-based PCPs leading this care team would be NPs, who would work with pharmacists and social workers, as well as community and home health workers.  MDs in the appropriate specialty within the central MEGA CHC would be available to each neighborhood clinic via the EHR, or with in-person consultation when needed.  Subspecialty consultation would be facilitated by the CHC staff electronically or in person working with collaborating subspecialties (5,6). 

            EHRs, already a required part of the PCMH, would be the central link between neighborhood clinic providers, faculty, their trainees and the THC primary care MD trainees and faculty in the central THC.  EHRs could facilitate this link and serve to convey the perspective of the CHC specialty and subspecialty consultants to the neighborhood-based teams, in response to their input of data and proposed therapeutic plan.  The EHR would also be essential for communication with other members of the neighborhood team to share data and convey plans for their role in care. 

Administration of the Collaborative Practice Team in the Neighborhood Clinic

            The neighborhood clinic team would be led by a Doctor of Nursing Practice (DNP) prepared NP with advanced competencies in leadership, systems-based practice and evidence implementation, who would serve as the clinic director, enlisting participation of other members of the team as needed and assuring the availability of electronic or personal interaction with CHC providers as needed. The neighborhood clinic administrator (CA) would be responsible to the clinic director for administering clinic logistics, including personnel, equipment and finances.  A neighborhood clinic advisory committee would consist of the CA, a NP, a representative from the central CHC and a majority consisting of patients served by the clinic. The advisory committee would establish and administer clinic policy in conjunction with clinic staff.

Interprofessional Education in the THC

            Interprofessional Education (IPE) occurs when two or more professions learn about each other, from and within each other’s area of expertise, to enable effective collaboration and improved health outcomes (4).  The number of healthcare practitioners educated in the United States has grown dramatically over the past decade (7).  The pipeline for APRNs, MDs assistants (PAs), and pharmacists has more than doubled in recent years.  If these practitioners are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth can help assure access to cost effective care.  The described CHC neighborhood clinic system enables such integration, if health professionals in training undergo IPE focused on achieving effective collaborative care.  This would involve training in “virtual teaming” through the EHR, and in experience collaborating with the CHC MDs.  The central MEGA THC described in the accompanying post (2) would provide some of the IPE necessary for the training of these NPs, as well as the primary care MDs receiving their GME via the central CHC who would collaborate with them.  

            Just as previously described for their MD in-training colleagues (8), NP trainees seeking to serve in neighborhood clinic leadership roles would provide primary care for a panel of patients in the neighborhood clinic for an extended period of ambulatory training.  Their NP faculty would provide supervision and also interact with their patients in order to provide continuity of care.  Upon graduation from a DNP program, these NP trainees would have gained expertise as nurse leaders of interdisciplinary healthcare teams, prepared to improve systems of care, patient outcomes, quality and safety.  Pharmacy faculty and their trainees would contribute to care, as would other team care faculty and trainees as required.  PAs would be exclusively located in central CHCs, so that they could work alongside of MDs.

Financial Support of Faculty, Trainees and Team Members

           We project that these neighborhood clinics will demonstrate a new venue for team care.  We have proposed a unique IPE and CP innovation which we believe will maximize the benefits of team care.  However, this innovation will require a funding mechanism which is flexible and supports team members according to their participation. In the past, team care has most frequently been referred to as the PCMH.  It has been attempting to evolve from an exclusive emphasis on care delivery to a focus on patients, families and communities; however, only limited definitive outcome data are available (9,10).  With a greater emphasis on the social determinants of health (11), population health, complex medication management and physical or virtual integration of behavioral and oral health into primary care, neighborhood practices and their central CHCs would be deploying teams with new members to bring expertise to these complex issues.  This array of health workers goes beyond the “traditional” professions to incorporate patient navigators, community health and home care workers, medical assistants, social workers and public health professionals focused upon prevention.  They will require a global funding mechanism for support. 

           Just as with the current THC-GME program (8), we propose that faculty salary and trainee salary be supported by Federal funding, which could be achieved via the CMMI demonstration grant as previously proposed (2).  All other funding would be derived from resources available to support the care of CHC patients, with a global funding mechanism if possible.

Advantages of MEGA THC Neighborhood Care For Lower-Income Medicare and Medicaid Patients

            As previously noted, current delivery systems frequently fail to meet the needs of high-risk, vulnerable Medicare and Medicaid beneficiaries (1).  They often have multiple co-morbid conditions and receive poorly coordinated care, leading to frequent hospitalizations and emergency department visits, increased rates of hospital readmissions, and suboptimal outcomes.  Thus, innovations in care delivery are needed for this burgeoning population (1), as proposed by the multiple initiatives summarized in Table I.   As previously emphasized, cost effectiveness will be extremely important if Medicare and Medicaid patients are to continue receiving necessary care (1).  Table II presents features of neighborhood clinic care which could achieve this goal. 

           Also, access to primary care, as well as geriatric care and mental health care by PCPs will continue to be a major problem (2).  Rather than exclusively depending on expansion of Medicare support for MD- PCP training in these areas, additionally integrating the substantial output of NPs (7) into this professional workforce for care via THC training would provide a more timely increase in cost-effective access.  Thus, we believe that the described NP role in the neighborhood clinic system of care will help address this problem for both urban and rural lower-income Medicare patients, as will facilitating their subspecialty care via EHR and in person consults in conjunction with partnering academic medical centers (6). 

           Proximity to a patient’s home would enable the local team to carry out home visits, in order to coordinate with home care (12) and community health workers (13).   The CP could also complement home hospice care when necessary. Emergency Medical Services community mobile care (14) could be utilized by the CP team to avoid emergency department visits, with the EHR facilitating their care.  EHRs can ensure that Medicare patients’ end-of-life plans are not lost in critical moments (15).

           Community health workers are particularly helpful in facilitating preventive services for these patients.  Their educational efforts in the home regarding nutrition, medication adherence, and eliminating fall hazards have been particularly valuable (13).

           Transitional care following hospital discharge can greatly reduce hospital readmission and emergency department care (16).  Neighborhood clinic collaborative practice can provide excellent transitional care and also avoid or delay nursing home care, assuming that the EHR from the hospital harmonizes with the EHR in the MEGA clinic and that the ED notifies the clinic of a discharge.  Finally, neighborhood clinic care where patients live allows better understanding of social determinants of care and addressing their impact (11). 

Conclusion

           In this series of three posts (1,2), we have described the MEGA CHC—a new paradigm for delivering universal, high-quality, cost-effective healthcare to lower-income Americans.  Establishing CHC neighborhood clinics in the proposed demonstrations would depend upon the establishment of MEGA THCs in the selected CHCs.  The neighborhood clinic NP trainees and faculty would coordinate care via EHRs with THC trainees and faculty who would contribute to the care as previously described.  The curriculum and training venues for the MDs has been previously described in detail (7) and could serve as a model for other professionals.

           Neighborhood clinics would provide a “front line” educational site for a variety of health professional students, who would obtain improved expertise in team-based primary care and increased capacity to address social determinants of health.  This approach would address a longstanding concern that medical schools and GME sites continue to train in a primarily hospital setting (or hospital adjacent) when a more prevention focused and interprofessional model must be based in communities. 

           As opposed to a new single payer system, this paradigm facilitates sustaining the ACA, with necessary modifications, in order to continue our multi-payer healthcare system.  Currently, we already maintain a major single payer system by support of Medicare, Medicaid and VA care, which covers more than 1/3 of Americans.  In future years, this population will expand and require even more care, as complex chronic disease more often is associated with increased longevity.  The burden on Federal and State budgets will be unmanageable and impact other Federal and State priorities, unless we develop a new paradigm of care for lower-income Americans.

            We believe that the proposed MEGA THCs and their neighborhood clinics will demonstrate that MEGA CHCs can achieve the Triple Aim-lower total cost of care, better population health outcomes, and an improved experience of care for patients and their families (17) for this population.  Comparing outcomes of CP in neighborhood clinics with that of the traditional PCMH approach in the central clinic would be of great interest.  Possible areas of evaluation might include cost of care, prevention implementation, and health outcomes, such as hypertension and Type 2 diabetes control.  A prominent consideration would be patient satisfaction.

           If successful, a CMMI demonstrations could serve to validate the advantage of a multi-specialty primary care group practice with neighborhood satellite clinics as a means of critically needed CHC expansion, while training the required workforce for an expanded CHC system of care for lower-income Americans. 

           Expansion of CHCs in medically underserved areas, such as rural settings and low-income urban CHCs, requires training of PCPs to fuel this expansion.  However, the number of trainees in U.S. medical residency programs will not meet this demand (18).  We have proposed development of NP-led neighborhood clinics affiliated with MEGA THC, in order to facilitate CHC expansion.

2,173 words

ACRONYMS

• CHC—Community Health Center
• NP – Nurse Practitioner
• THC—Teaching Health Center
• PCP—Primary Care Professional
• EHR—Electronic Health Record
• CP—Collaborative Practice
• IPE—Interprofessional Education
• PCMH—Patient Centered Medical Home
• DNP – Doctor of Nursing Practice
• THCGME—Teaching Health Center Graduate Medical Education Program
• CMMI—Center for Medicare and Medicaid Innovation
• EMS—Emergency Medical Services
• ED—Emergency Department
• AMC—Academic Medical Center
• ACA—Affordable Care Act

 Table I

Advantages of MEGA CHC Neighborhood Clinics For Care of Low-Income, Vulnerable Medicaid and Medicare Patients

• Cost-effective care (Table II)
• Increases access to PCP geriatric and mental health care
• Increases access to subspecialty care via EHR and in person consults via AMC Partnerships (6)
• Access to pharmacist guidance re: complex regimens of medication
• Facilitates integration of community health workers educational efforts into team care (13,16)
• Facilitates home health care, thereby delaying or avoiding assisted living or nursing home care (12)
• Utilizes EMS community medicine care (14)
• Facilitates development and communication of advanced directives via EHR documentation (15)
• Facilitates preventive care (16)
• Provides transitional care to decrease hospital readmissions and ED care (17)
• Allows better understanding of social determinants of care and addressing their impact (11)

 Table II

Cost Effectiveness of CHC Neighborhood Clinic Care

• Projected yearly salary of NPs less than $100,000/year (19)
• Decreased utilization of emergency departments and retail clinics
• Delayed or avoidance of nursing home care
• Decreased drug cost via 340B Federal drug pricing program for CHCs
• Elimination of MD billing cost or administrative cost for Medicaid managed care
• Decreased fragmentation of care with effective access to and utilization of consultations
• Malpractice liability protection for CHC under Federal Tort Claims Act
• Effective chronic disease management
• Facilitates preventive care
• Provision of cost-effective integrated dental and mental health services
• Facilitates transitions in care, an important strategy for reducing preventable hospitalization and readmissions

 References

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