Before this decade is over, two sea changes in the public health system will
converge. The first comes about among Rural Health Centers (RHC's) and Federally
Qualified Health Centers (FQHC's). These safety net role players in the
intrinsic fabric of community health are undergoing structural changes not
foreseen by their creators1. RHC's, in particular, face painful
recruitment obstacles, as they strive to find primary care clinicians, and
increasingly look to hospitals for franchise-type arrangements in order to meet
infrastructure needs2. FQHC's are reacting to pressure to augment
their battle against the compelling urban problem of health disparities with new
service lines – dental health, mental health day treatment, and elder
care3. Both have accepted, perhaps begrudgingly, the need to seek
external charitable funding to sustain operations2,3.
A second sea change, the production of the first doctoral-prepared nurse
practitioners (DNP's), is bubbling slowly through the health system. As a
practice-based professional, the DNP ostensibly will not only have advanced
clinical skills but also leadership qualifications. By 2010, the first wave of
DNP's will engage the health system. Nurse practitioners have evolved over a
30-year period; changes in practice and prescription privileges, reimbursement,
enabling legislation, credentialing, and accreditation have occurred slowly – to
the extent that nurse practitioners have demonstrated that they are clinically
skilled, safe, affordable, quality-oriented, collaborative
practitioners.4 Not surprisingly, the evolution of a practice
doctorate in a practice discipline is a legitimate progression. The growing
complexities of care, the aging of the U.S. population, and the dwindling number
of primary care physicians all contribute to the need for increased knowledge
and practice competency in advanced clinical nursing practice5.
Community health centers and nurse practitioners have been called "natural
partners"6, and we see the convergence of RHC/FQHC structural changes
and the introduction of DNP's as an immense opportunity to further our
understanding of how health status, health resources, and access are
inter-dependent. Not since the mid-1980s, when the physician assistant model was
standardized and recognized7 (the nurse practitioner movement was
well under way by the late 1970s8), has the public health system had
an opportunity to assess the impact of a new clinician on health status and the
health of communities.
As the sea changes converge, there will be many, many policy issues to
explore. To be sure, both the RHC/FQHC and nurse practitioner models seek to
achieve equal access to equal health care in geographical areas where neither is
easy to accomplish. The timing also is excellent: Public health has retuned to
systems thinking in order to assess the realities of practice within complex
environments9. As a foundation for thoughtful research we propose a
framework for analysis of the evidence, based on the classic work of
Donabedian10 and Nagel11, described in Table 1 below, that
builds upon four hierarchical constructs of health policy: efficiency,
effectiveness, efficacy, and equity.
This will be an exciting time for community health professionals and students
alike – as the opportunity presents itself for ground-level research.
summary="Converging Movements: RHC/FQHC Structural Changes and Introduction of DNP's Proposed Framework for Analysis"
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Table 1: Converging Movements: Rural Health
Center(RHC)/Federally Qualified Health Centers (FQHC) Structural Changes and
Introduction of Doctoral-prepared Nurse Practioner's (DNP) Proposed Framework
for Analysis |
Element & Description |
High Level Metric |
Examples of Metrics |
Analytical Framework |
EFFICIENCY
Efficiency is simply the cost per
unit of something |
Cost per Benefit |
Cost per visit, or Cost per episode of care
or, Cost per
FTE |
Does efficiency increase or decrease? With the introduction of
new financial structure and a new clinician, how is it measured?
At a
high level, one would look for improved efficiencies. |
EFFECTIVENESS
Effectiveness is the comparison
of various efficiency measures with other throughput metrics, usually over
time. |
Cost per Benefit vs. Cost per Benefit
or, Cost per Event at
Time1
vs. Cost per Event at Time2 |
Pre-Post measurements using DNP start-date as boundary.
For
example: Costs of diabetic retinal exams, or rates of fully immunized
4-year-olds |
What trends are visible? Are these relationships direct or
indirect?
A reasonable starting assumption is that adding a DNP to
community health center service mix will increase effectiveness, especially in
secondary and primary prevention services. |
EFFICACY
In this framework, efficacy is the
overall net benefit when the trade-offs between the costs of both care and
quality are considered. |
Benefits considered with Costs, along an outcome measure |
Convergence or regressed point where increased costs do not
increase (or lower) benefits, for example:
Cost per episode of care for
chronically ill adults paired with reductions in acute events. |
A certain level of expenditure is mandatory before satisfactory
quality outcomes, and at some point increasing costs add very little to quality
measures. Many quality outcomes don’t improve overnight (weight loss is a good
example).
One viable question for RHC’s and FQHC’s is: Can the center
sustain the added costs of a new clinician while, over time, health care
outcomes (hopefully) improve? |
EQUITY
Equity represents our hopes for fair
and just health care. |
Benefits = f{cost, quality, time, values, social goals} |
Survey data (below) compared to metrics (above), for
example:
(1) Positive community opinion, (2) self-reported health assessment,
(3) numbers of targeted populations receiving sustained, appropriate, health
services -- compared with cost per episodes of care. |
Will the convergence of RHC/FQHC structural changes and the
addition of DNPs meet our hopes for fair and just care to the people within
community health center target areas? |
References
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About the Authors
Patricia House, MPH, PhD, is a project consultant for the Global Health
Division of Electronic Data Systems, Boston, and a longtime APHA member.
Lynne E. McEnroe, MA, MSN, APRN, BC, is executive assistant to the dean,
School of Nursing, University of Medicine and Dentistry of New Jersey, Newark,
N.J., and is an Advanced Practice Community Health Nurse.