Shortage Of Primary Care Providers Research Articles

Virtually Better Diabetes Care?

Despite growing awareness of the problem, the diabetes epidemic shows no signs of abating and continues to pose a public health problem of grave concern (1). Nonpharmacologic interventions focused on lifestyle modifications, including diet and exercise, remain a major component of therapy. Individualized nutrition therapy has been shown to be effective for improvement of the metabolic profile and weight loss. However, most studies of popular diets are usually of short duration and have high attrition rates (15–50% within 1 year) (2). Adherence to any prescribed diet is a real challenge, especially when we are surrounded by easily accessible, processed food of high caloric and low nutritional value. It is therefore not surprising that lifestyle modification often fails, and as health care providers (HCPs), we find ourselves compelled to add more and more pharmacotherapies and often recommend metabolic surgery to achieve therapeutic goals. Indeed, despite significant advances in pharmacotherapy, there has been no significant change in the percentage of people who achieve therapeutic goals (3). A key question that needs to be addressed is how HCPs can help patients adhere to a treatment plan that will enable them to achieve and sustain improvements in metabolic control. One of the most essential components of diabetes care is access to an HCP. There is a significant shortage of primary care providers and endocrinologists in the United States, with the rising number of patients with diabetes outstripping the number of HCPs (4). Endocrinologists are asked to see more patients in less time, and new patients may have to wait for months to be seen. The problem is even worse for patients in remote areas, who must travel long distances to be seen. It is also commonly observed that patients …

Nurse Practitioner Role Transition and Identity Development in Rural Health Care Settings: A Scoping Review.

The purpose of this scoping review was to explore the literature regarding the nurse practitioner (NP) role transition and professional identity development at rural health care settings. Because of the shortage of primary care providers, NPs are meeting the demand for primary care in rural areas. Arksey and O'Malley's six-stage methodological framework for scoping reviews guided this systematic literature review, which resulted in selection of 145 sources. Three major themes emerged: NPs in rural clinical practice, defining NP professional identity, and role transition to an NP identity. Further research is needed to guide education program leaders on curriculum development. Rural health care facilities and nursing programs should partner in the orientation and continuing education needs of NPs to prepare and support their role transition and professional identity development. NPs will be instrumental in providing access to quality primary health care in rural communities.

Barriers to Preceptor Placement for Nurse Practitioner Students.

Advanced practice registered nurses (APRNs) are positioned to fill healthcare gaps in the looming primary care provider shortage, if clinical educational needs can be met. Issues with preceptor placements for APRNs have been hotly debated in nursing education but not well studied. This article presents a case study of a quality improvement project, describing the experiences of a Clinical Preceptor Placement Coordinator for APRN students for a small Midwestern university. Barriers identified in finding preceptor placements for students are delineated, and suggestions for solutions and further research are given to address this growing problem.

Commentaries on health services research

Commentaries on health services research

Satisfaction and Technology Evaluation of a Telehealth Robotic Program to Optimize Healthy Independent Living for Older Adults.

With the growth in the aging population, and shortage of primary care providers, telehealth programs are needed to optimize healthy independent living for older adults. The purpose of this study was to evaluate a nurse-led intervention program delivered through a telepresence robot to promote healthy lifestyles and address chronic illness management among older adults living independently in a retirement community. Telepresence robots provide two-way video-mediated communication with remote in-home navigation. Satisfaction and technology evaluation ratings of the Telehealth Community Health Assistance Team (T-CHAT) program, as well as qualitative data from open-ended questions, were obtained from 26 older adults and 7 nurse practitioner students. On a scale from 1 = strongly disagree to 5 = strongly agree, satisfaction ratings were positive for usefulness (M = 3.90), ease of use (M=4.16), and acceptability (M = 4.06). Technology evaluation ratings were high for all sessions (M = 4.35). Older adults and nurse practitioner students were highly complementary of the program. Areas for improvement were identified. The T-CHAT program demonstrated high ratings for satisfaction (usefulness, ease of use, acceptability) and for evaluation of the telepresence robot technology. Further refinement of the T-CHAT program is warranted, as is testing outcomes of this potentially viable mode of healthcare delivery. Robotics is the wave of the future and provides an innovative mode of delivery to address health promotion and chronic illness management in older adults. Satisfaction and technology evaluation of robotic technology is paramount prior to implementation of such programs into practice.

Past, present, and continued need for provider status legislation: Navigating clinical practice with significant sustainability barriers

The pharmacy profession has advanced remarkably, however, pharmacists have yet to obtain provider status at the federal level. Establishing pharmacists as providers is imperative in light of the growing shortage of primary care providers and need to provide care for medically underserved populations. Academic reform, professional development and legislation have all contributed to the furtherment of provider status. Yet, the cornerstone to obtaining this status lies in imminent changes at the health care and interprofessional collegial levels in conjunction with professional perseverance and legislative action. These actions will help ensure pharmacists as integral partners on collaborative health care teams in clinical service provision for managing patients' chronic conditions and medications, to ultimately, improve access to quality care and patient health outcomes.

Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes.

Background: For decades, U.S. rural areas have experienced shortages of primary care providers. Nurse practitioners (NPs) are helping to reduce that shortage. However, NP scope of practice regulations vary from state-to-state ranging from autonomous practice to direct physician oversight. The purpose of this study was to determine if clinical outcomes of older rural adult patients vary by the level of practice autonomy that states grant to NPs. Methods: This cross-sectional study analyzed data from a sample of Rural Health Clinics (RHCs) (n = 503) located in eight Southeastern states. Independent t-tests were performed for each of five variables to compare patient outcomes of the experimental RHCs (those in “reduced practice” states) to those of the control RHCs (in “restricted practice” states). Results: After matching, no statistically significant difference was found in patient outcomes for RHCs in reduced practice states compared to those in restricted practice states. Yet, expanded scope of practice may improve provider supply, healthcare access and utilization, and quality of care (Martsolf et al., 2016). Conclusions: Although this study found no significant relationship between Advanced Registered Nurse Practitioner (ARNP) scope of practice and select patient outcome variables, there are strong indications that the quality of patient outcomes is not reduced when the scope of practice is expanded.

Predictors of nurse practitioner retention

Increased utilization of nurse practitioners (NPs) has been proposed to reduce the shortage of primary care providers, so identifying factors related to retention of NPs is important for health care organizations. The purpose of this study was to examine the relationship of Misener Nurse Practitioner Job Satisfaction Scale factors and nurse demographic characteristics with NP retention, as defined by the number of years at the current position and intention to leave the current position within 5 years. A survey was distributed via email to members of the Texas NP Organization. Three hundred fifteen NPs participated in the study. Years of experience (p < .001), salary (p = .018), and benefits (p = .007) were significantly associated with longer duration of employment at the current position, after controlling for the other variables in the linear regression model. After adjusting for the other variables in the logistic regression model, higher challenge/autonomy factor scores (p = .016) and higher annual salary (p = .032) were associated with significantly lower odds of intention to leave the current position within 5 years. Interventions to increase NP autonomy and facilitate employment in positions with more competitive salaries are likely to improve NP retention.

The impact of nurse practitioner regulations on population access to care

BackgroundBy 2025, experts estimate a significant shortage of primary care providers in the United States, and expansion of the nurse practitioner (NP) workforce may reduce this burden. However, barriers imposed by state NP regulations could reduce access to primary care. PurposeThe objectives of this study were to examine the association between three levels of NP state practice regulation (independent, minimum restrictive, and most restrictive) and the proportion of the population with a greater than 30-min travel time to a primary care provider using geocoding. MethodsLogistic regression models were conducted to calculate the adjusted odds of having a greater than 30-min drive time. FindingsCompared with the most restrictive NP states, states with independent practice had 19.2% lower odds (p = .001) of a greater than 30-min drive to the closest primary care provider. DiscussionAllowing NPs full autonomy to practice may be a relatively simple policy mechanism for states to improve access to primary care.

Addressing the Shortage of Geriatric Specialists.

With a population that is increasingly "gray," our nation faces a shortage of primary care providers who specialize in geriatrics. The number of geriatricians per 10,000 adults older than 65 years of age has decreased steadily since 2000. Health care providers from all disciplines (medicine, nursing, and pharmacy) tend not to choose geriatrics as a specialty area. Some are intimidated by the complexity of caring for elderly patients with geriatric syndromes and multiple morbidities. Others, who have little exposure to geriatrics in their undergraduate and graduate programs, are simply unaware of the personal and professional rewards associated with practice in geriatrics. Some choose to pursue more lucrative career paths. Regardless, geriatrics is a rewarding area of specialty, and pharmacists can pursue additional training to become specialists. Few pharmacy curricula offer intense exposure to geriatrics and elder health care. Numerous ways exist for pharmacists to help close the geriatric care gap.

Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review.

Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine.

Factors That Influence Job Choice at the Time of Graduation for Physician Assistant Students.

Research and data analysis show that there is a shortage of primary care providers throughout the United States. Physician assistants (PAs) play an important role in health care delivery; however, the percentage of PAs practicing in primary care has dramatically decreased in the past 15 years. The purpose of this study was to identify potential factors that influence PA students' first job choice following graduation from a PA program to determine whether they have a relationship to the choosing of primary care. The 2016 End of Program Survey data were analyzed using a multinominal logistic regression to determine what factors influenced PA students' selections of primary care as their first job choice: individual factors, program factors, and external factors. Of the 3038 subjects, 269 (8.9%) accepted a job in primary care, 847 (27.9%) accepted a specialty job, and 1922 (63.3%) did not accept a job. When comparing no job accepted versus primary care job choice, marital status and racial/ethnic differences influenced first job choice. Financial factors were also found to be significant predictors. In the second model, comparing specialty versus primary care job choice, marital status influenced first job choice along with financial factors. In addition, one program variable (moderate clinical rotation experience) was found to be statistically significant in the model of specialty versus primary care job choice. Financial factors were found to be the greatest predictor in first job choice. Focusing on policy to help reduce student debt and increase reimbursement rates could help increase the number of students choosing primary care.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder—Case studies in Maryland, Rhode Island, and Vermont

PurposeThe United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states—Maryland, Rhode Island, and Vermont – adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. MethodsWe conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. ResultsOverall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. ConclusionsThe OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

Nurse Practitioners, Physician Assistants, and Physicians Are Comparable in Managing the First Five Years of Diabetes

BackgroundIncreasing use of nurse practitioners and physician assistants is a possible solution to the shortage of primary care providers in the United States, but the quality of care they provide is not well understood. MethodsBecause the scope of practice of the 3 provider types is similar in the Veterans Health Administration, we determined whether patients managed by primary care nurse practitioners, physician assistants, or physicians had similar hemoglobin A1c levels at comparable times in the natural history of diabetes. Our retrospective cohort study examined veterans with newly diagnosed diabetes in 2008, continuous primary care from 2008 to 2012, and more than 75% of primary care visits with nurse practitioner, physician assistant, or physician. ResultsOf the 19,238 patients, 95.3% were male, 77.7% were white, and they had a mean age 68.5 years; 14.7%, 7.1%, and 78.2% of patients were managed by nurse practitioners, physician assistants, and physicians, respectively. Median hemoglobin A1c was comparable at diagnosis (6.6%, 6.7%, 6.7%, P > .05) and after 4 years (all 6.5%, P > .5). Hemoglobin A1c levels at initiation of the first (7.5%-7.6%) and second (8.0%-8.2%) oral medications for patients of nurse practitioners and physician assistants compared with that of physicians was also similar after adjusting for patient characteristics (all P > .05). Nurse practitioners started insulin at a lower hemoglobin A1c (9.4%) than physicians (9.7%), which remained significant after adjustment (P < .05). ConclusionsAt diagnosis and during 4 years of follow-up, diabetes management by nurse practitioners and physician assistants was comparable to management by physicians. The Veterans Health Administration model for roles of nurse practitioners and physician assistants may be broadly useful to help meet the demand for primary care providers in the United States.

Perceptions of pharmacists’ role in the health care team through student-pharmacist led point-of-care screenings and its future application in health care

IntroductionThe public is largely unaware of changing pharmacy roles and continues to underutilize pharmacists as mainly a dispensing service, often overlooking direct patient care components. This paper evaluates the public perceptions of pharmacists’ through student led point-of-care screenings and comprehensive medication reviews. MethodsAn IRB approved longitudinal retrospective study design was used to survey participants who attended College of Pharmacy sponsored health fairs in 2013. The survey contained questions related to patient understanding of the current pharmacy scope of practice, patient’s reported level of comfort with the expanding roles of pharmacy, insurance coverage, demographics, income and whom the patients report that they seek first for medical related advice. ResultsOne hundred participants were surveyed. By a large majority, the health care practitioner that patients reported that they currently sought out for general health information was a physician. All of the participants reported that they considered pharmacists as reliable sources of general health information. Of the 96 participants that completed the survey question regarding their willingness to seek out a pharmacist in the future to have their blood pressure, blood sugar, cholesterol, and/or bone density checked, 89 (92.7%) surveyed answered yes. Only 50 patients (50%) reported being aware that pharmacists have the capability to perform these point-of-care screenings. Participants responded that they felt “comfortable” (78 patients, 83.4%) followed by “trusting” (36 patients, 38.7%). DiscussionThe patients surveyed recognized pharmacists as the medication experts; however, many did not understand the capacity to which pharmacists’ scope of practice allows them to deliver care to patients. In this study, almost all of the patients stated that they would consider seeking out a pharmacist to receive point-of-care screenings, but only half were aware that a pharmacist is capable of conducting these screenings. All felt that pharmacists are a reliable source of general health information and medication related needs, regardless of the patients’ education level or household income. ConclusionWith the shortage of primary care providers, expansion of the scope of pharmaceutical practice is necessary. Although the public may not fully understand pharmacists’ scope of practice, they are comfortable with pharmacists’ knowledge related to general health needs outside of medications. The reported public comfort and trust of pharmacist knowledge and skills justify expanding the scope of pharmaceutical practice.

Establishing a Viable Workforce Pipeline of Primary Care Nurse Practitioners: Benefits of a Health System and Academic Partnership.

Maldistribution and shortages of primary care providers, changing reimbursement structures, movement from inpatient to community-based models of care, an aging population, and health care reform lead to increased numbers of patients seeking care. All of these phenomena have a part in creating a health care landscape that requires industry leaders enlist innovative strategies to meet the health care needs of their communities. Delivery of high-quality, efficient care by qualified providers is essential for the success of any health care system. Partnerships between health systems and academic centers of learning to develop a pipeline of providers is one inventive approach that can address primary care workforce needs. The purpose of this article was to share an example of an academic/health care system partnership to address primary care workforce needs in a rural Midwestern region.

Knowing Your Limits: A Qualitative Study of Physician and Nurse Practitioner Perspectives on NP Independence in Primary Care.

The shortage of primary care providers and the provisions of the Affordable Care Act (ACA) have spurred discussion about expanding the number, scope of practice (SOP), and independence of primary care nurse practitioners (NPs). Such discussions in the media and among professional organizations may insinuate that changes to the laws governing NP practice will engender acrimony between practicing physicians and NPs. However, we lack empirical, descriptive data on how practicing professionals view NP independence in primary care. The aim of the present study was to explore and describe the attitudes about NP independence among physicians and NPs working in primary care. A qualitative study based on the principles of grounded theory. Thirty primary care professionals in Missouri, USA, including 15 primary care physicians and 15 primary care NPs. Semi-structured, in-depth interviews, with data analysis guided by grounded theory. Participants had perspectives that were not well represented by professional organizations or the media. Physicians were supportive of a wide variety of NP roles and comfortable with high levels of NP independence and autonomy. Physicians and NPs described prerequisites to NP independence that were complementary. Physicians generally believed that NPs needed some association with physicians for patient safety, and NPs preferred having a physician readily accessible as needed. The theme "knowing your limits" was important to both NPs and physicians regarding NP independence, and has not been described previously in the literature. NP and physician views about NP practice in primary care are not as divergent as their representative professional organizations and the news media would suggest. The significant agreement among NPs and physicians, and some of the nuances of their perspectives, supports recommendations that may reduce the perceived acrimony surrounding discussions of NP independent practice in primary care.

Thematic elements of the postgraduate NP residency year and transition to the primary care provider role in a Federally Qualified Health Center

Background/Objective : Although the literature supports that nurse practitioners provide quality primary care resulting in excellent outcomes, the transition from nurse pracitioner education to practice is often difficult. Postgraduate residency programs have been suggested to help new nurse practitioners successfully transition, and studies indicate that most new nurse practitioners are interested in postgraduate residencies; however, little is known about how residencies facilitate transitioning. We sought to understand the experience of nurse practitioners in a residency program in the United States and how the program facilitated their transition to the role of primary care provider. Methods : Reflective journals of 24 Residents who completed the first primary care nurse practitioner residency in the United States were analyzed using Content Analysis. Results : Four to nine themes for each month and one theme for each yearly quarter were identified. Residents went from feeling shocked and overwhelmed to becoming confident, competent primary care providers, committed to underserved populations. Transitioning conditions ( e.g. , on-call experience) and specific facilitators ( e.g. , engaged preceptors) and stressors ( e.g ., managing chronic pain and reqests for opioids) that impacted their transition were also identified. Conclusions : The findings are significant as the United States addresses the shortage of primary care providers and models for postgraduate residencies and fellowships for nurse practitioners and other advanced practice registerered nurses emerge. The findings also represent the first qualitative data that reflect the experience of nurse practitioner Residents and provide rich insight into the overall experience of a one year residency, as well as facilitating and stressful factors. Organizations that are developing or refining nurse practitioner residencies or fellowships should consider these findings and discuss ways to address them with both nurse practitioner Residents and preceptors, as well as program and organizational leadership.

Improving the Education and Training of Primary Care Nurse Practitioners to Meet the Healthcare Needs of Long-Term Cancer Survivors.

The United States has a well-documented shortage of primary care providers (PCPs) and oncologists. Cancer survivors are living longer because of advances in treatment, and, consequently, more are seeking survivorship care from PCPs; this trend is predicted to continue. One proposed solution is to increase the use of nurse practitioners (NPs). However, most NP programs do not provide adequate training or education that is specific to the needs of long-term cancer survivors.&nbsp.

Development of an Automated Healthcare Kiosk for the Management of Chronic Disease Patients in the Primary Care Setting.

An increase in the prevalence of chronic disease has led to a rise in the demand for primary healthcare services in many developed countries. Healthcare technology tools may provide the leverage to alleviate the shortage of primary care providers. Here we describe the development and usage of an automated healthcare kiosk for the management of patients with stable chronic disease in the primary care setting. One-hundred patients with stable chronic disease were recruited from a primary care clinic. They used a kiosk in place of doctors' consultations for two subsequent follow-up visits. Patient and physician satisfaction with kiosk usage were measured on a Likert scale. Kiosk blood pressure measurements and triage decisions were validated and optimized. Patients were assessed if they could use the kiosk independently. Patients and physicians were satisfied with all areas of kiosk usage. Kiosk triage decisions were accurate by the 2nd month of the study. Blood pressure measurements by the kiosk were equivalent to that taken by a nurse (p=0.30, 0.14). Independent kiosk usage depended on patients' language skills and educational levels. Healthcare kiosks represent an alternative way to manage patients with stable chronic disease. They have the potential to replace physician visits and improve access to primary healthcare. Patients welcome the use of healthcare technology tools, including those with limited literacy and education. Optimization of environmental and patient factors may be required prior to the implementation of kiosk-based technology in the healthcare setting.