Who's Who in Primary Care
New Providers Move to Center Stage
By Sandy Graham
The evolution in primary care calls on the skills of a wide range of professionals, all working together to provide efficient, effective, integrated care.
"In addition to physicians, nurse practitioners and physician assistants, the members of the team could include registered nurses, case managers, community health workers, nutritionists or dietitians, mental health professionals, pharmacists and others," says Mary Wakefield, PhD, RN, administrator of the Health Resources and Services Administration in the U.S. Department of Health and Human Services.
But defining the roles of various providers is no easy task. Ultimately, the primary care system must be engineered so "we'll be using the right people for the right services," says Colorado state Sen. Jeanne Nicholson, RN, who represents Boulder, Jefferson and several mountain counties. That may require regulatory changes and new reimbursement policies.
Over the decades, professionals' allowed duties have expanded and changed. In the 1960s when Nicholson became a nurse, RNs were not allowed to use stethoscopes to listen to people's chest sounds because that was considered a skill that exceeded their training, she recalls. In the 1800s, only physicians were considered skilled enough to use thermometers. While those days are long gone, there continues to be debate over how to divide the work of primary care among many kinds of providers.
Only a fraction of medical issues typically seen in primary practice requires a physician's skills to diagnose and treat, says Nancy Smith, PhD, dean of Beth-El College of Nursing and Health Sciences at the University of Colorado at Colorado Springs. A 1986 paper by the U.S. Office of Technology Assessment looked at several early studies of primary care that concluded anywhere from 50 percent to 90 percent of the tasks routinely performed by physicians could be handled by physician assistants or nurse practitioners. And a new review of more than 100 clinical trials and studies from 1990 to 2008 concluded that care by nurse practitioners and nurse-midwives was as good as or sometimes better than that of physicians.
Smith, a fellow of the American Academy of Nurse Practitioners, sees opportunities to delegate more responsibility to skilled, midlevel providers, particularly advanced practice nurses. This is critical, Smith says, since the current health care system won't have enough physicians to meet the growing demand for primary care.
"Nurses should be full partners – not only with physicians, but with other providers – in redesigning the health care system in this country," Smith says. The 2010 report "The Future of Nursing: Leading Change, Advancing Health" from the Institute of Medicine reached the same conclusion and called for regulatory changes that would allow nurses to practice to the full extent of their education and training.
Allowing nurses, physician assistants and other health professionals to provide more primary care does not compromise care. A 2008 report by the Colorado Health Institute for the Collaborative Scopes of Care Advisory Committee, appointed by then-Gov. Bill Ritter Jr., reviewed hundreds of scientific studies of the care given by advanced practice nurses (such as nurse practitioners in family medicine or gynecology), physician assistants (who receive extensive medical training but must practice under physician supervision) and dental hygienists. Based on the review, the report concluded:
- Generally, there are no differences in patient outcomes or satisfaction comparing the care provided by physician assistants with physicians' care.
- Advanced practice nurses working in teams with other health professionals deliver quality health care comparable to physicians and receive high patient-satisfaction ratings.
- Dental hygienists in unsupervised practice competently deliver preventive services such as teeth cleaning with quality "at least comparable" to that of dentists. However dental insurance doesn't always directly reimburse hygienists. The committee recommended further study of reimbursement policies.
Sharing responsibility for primary care can require a period of adjustment for some practitioners.
"There are certain physicians, and I think it's a small number, who are not so positive about the roles of nurse practitioners and physician assistants in particular," says Mark Earnest, MD, PhD, director of Interprofessional Education at the University of Colorado Denver Anschutz Medical Campus. But, he notes, most physicians now in practice have been trained in the traditional system and know no alternative. The university is working to ensure its students in all health sciences are trained to work with other professions and understand the advantages of the team approach. (See story, 'REACH'-ing for Change.)
Smith believes that the regulatory, payment and acceptance issues will be resolved eventually, allowing the development of a new model for primary care and addressing some of the looming professional shortages.
"In this new model, we are going to be able to go back to some of the benefits of a real interprofessional team [that] can really delegate functions to each professional's appropriate skill level," she says. "That's really where we'll achieve quality, efficient, effective and accessible care."
|Primary Care from A to Z
Advanced practice nurses. The first nurse practitioner program was founded at the University of Colorado Health Sciences Center School of Nursing in 1965. Advanced practice nurses (APNs) are registered nurses (RNs) who have completed master's degrees or doctorates in nursing practice and passed a national exam, allowing them to work in general practices or a specialty such as family medicine, pediatrics or anesthesiology. APNs are independently licensed in Colorado. Nursing regulations specify that newly certified APNs must complete a process with a physician or a physician and an APN prescriber preceptor and mentor to gain independent prescriptive authority. There are about 250,000 working APNs in the nation.
Behavioral health practitioners. Increasingly, mental health care and treatment of substance use disorders are being integrated into medical care as practitioners recognize that "health" incorporates both mind and body. Social workers, therapists, counselors, psychologists, psychiatrists and professionals treating an array of behavioral health conditions are in this group. Training and licensure requirements vary.
Dental hygienists. Dental hygienists provide oral assessment, disease prevention measures such as sealants and fluoride, and nutrition and hygiene education in clinical, school and public health settings. Other tasks vary by state, all of which license hygienists. There are about 174,000 dental hygienists in the country.
Dentists. Most of the nearly 140,000 dentists in the United States are in general practice. Most students earn college bachelor's degrees and then enter dental school for four years to earn doctor of dental medicine or doctor of dental surgery degrees. Specialties such as orthodonture require another two to four years of training. All dentists pass written and practical licensure exams.
Health educators. These professionals encourage healthy lifestyles and behaviors by teaching individuals or communities how to prevent disease, injuries and other problems. Most educators hold bachelor's degrees from health education programs, but some earn master's degrees. Certification is optional. There are about 66,000 U.S. health educators.
Medical assistants. Medical assistants traditionally have performed the administrative and clerical tasks in a health care office but are expanding their roles to include duties such as taking medical histories and recording vital signs, performing basic lab tests, explaining treatment procedures, preparing people for examinations and assisting during examinations. There are no formal education or training requirements although some assistants complete short training programs.
Pharmacists. Many pharmacists distribute prescription drugs at the order of authorized health professionals. Increasingly, they are integrating evidence-based clinical pharmacy services into the care and management of high-risk, high-cost, complex patients. They hold doctor of pharmacy degrees, which are given after four-year programs that follow some college-level training. They also pass a series of licensure examinations. There are 270,000 pharmacists in the country.
Physician assistants. The first physician assistant (PA) training program was established at Duke University in 1965. PAs are trained and licensed to practice medicine with limited supervision by a physician; they complete four to seven years of postsecondary education and pass a national certification exam. A PA is concerned with preventing, maintaining and treating human illness and injury by providing a broad range of health care services, frequently in primary care. There are about 75,000 PAs nationally.
Physicians. Medical doctors (MDs) or doctors of osteopathy (DOs) both attend four-year, postbaccalaureate medical training programs. Primary care physicians receive several years of additional training, through residency programs, in family or general medicine, obstetrics and gynecology, pediatrics or internal medicine. MDs and DOs are licensed in all 50 states. There are about 661,000 working physicians in the United States.
Registered nurses. Colorado requires RNs to graduate from a professional nursing program in which a person earns either an associate's degree or bachelor's degree, then passage of a national examination for licensure as an RN. According to federal statistics, RNs constitute the nation's largest health care occupation with 2.6 million jobs. They work in a variety of settings and have wide-ranging duties including education and primary care.
You. Any person seeking care is an integral part of the team and must collaborate with health professionals to address individual health needs.
Primary care teams continue to evolve. They may also have other players such as "health navigators" who guide people through the complex system, care coordinators who ensure people receive care in the right settings and community health workers who provide education and services especially to underserved populations.
Note: All workforce statistics from the U.S. Bureau of Labor Statistics, 2008.