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Nurse practitioners fill a gap in rural health care

This article first appeared in the St. Louis Beacon, Dec. 15, 2011 - There are no doctors in Pilot Grove, Mo., but the town's 825 residents have perhaps the best alternative source of health care, thanks to an enterprising nurse practitioner. She is Laurie A. Beach, who owns and operates the Pilot Grove Rural Health Clinic in the central Missouri town.

Beach also grew up in Pilot Grove, which is near Boonville. That she decided to return home and open a medical services business is unusual, health officials say, because few of the state's 367 rural clinics are owned by nurse practitioners.

Health-care providers point to Beach as an example of the growing role that nurse practitioners are playing to bring medical care to rural Missouri communities where primary-care doctors are nonexistent or in short supply. Before opening the clinic in 2005, Beach worked for two decades at a health clinic at the University of Missouri at Columbia, where she also got her nurse practitioner training. Her clinic draws thousands of patients from within a 50-mile radius.

Nurse practitioners represent one of four specialties for people who obtain certification as advanced practice registered nurses, or APRNs. The other three are certified registered nurse anesthetists, nurse midwives and clinical nurse specialists. APRNs must complete over two years of college work for a master's degree, followed by testing by a certification board. Missouri has more than 6,200 APRNs, two-thirds of whom are nurse practitioners. Depending on the specialty, average annual salaries range from $79,000 to $91,000.

Because of their advanced medical training, nurse practitioners are equipped to perform many functions of primary-care doctors, including diagnosing and managing some acute and chronic diseases and writing prescriptions. Their authority to write prescriptions in Missouri was expanded this month to include controlled substances. This new rule applies to all APRNs except nurse anesthetists.

Nurse Practitioners Fill A Gap

The demand for advanced practice RNs is expected to rise due mainly to projected growth in the number of patients, the influential federal Institute of Medicine says in a report, IOM: Future of Nursing Report Recommendations. Given that millions more patients are expected to gain access to health coverage through the Affordable Care Act (ACA), the report says the health system should tap into the capabilities of advanced practice RNs.

In Missouri, the new health-care law is projected to give a minimum of 374,000 more patients access to health insurance, which could put primary care within their reach. Because Missouri is not producing or attracting enough primary-care doctors, many say nurse practitioners could provide some of that care.

"Many of our physicians are going into specialties instead of family practice," says Jill Kliethermes, the chief executive officer of the Missouri Nurses Association. "A good place for our nurse practitioners to fit in is by being primary-care providers, especially in rural Missouri."

In addition, she says, using nurse practitioners saves money. They are reimbursed 85 percent of what the federal government pays a doctor to treat a Medicare patient.

But that doesn't mean nurse practitioners are universally accepted. Some patients and businesses prefer physicians even though the evidence suggests that nurse practitioners are just as capable and, in some instances, more empathetic toward patients. Patricia Brennan, a former health-care financial analyst at Barnes-Jewish Hospital, especially values the work of nurse practitioners. She used to work with patients sent to her employer for job-connected health needs, ranging from drug tests to work-related injuries. Although she personally didn't mind receiving care from nurse practitioners, Brennan said a small number of companies requested doctors see their workers.

"Of course, we had to honor what the employers requested because they were paying the bills," she says. "In many ways the nurse practitioners were better at observation and documentation than the physicians. As in most things, however, there were exceptions to this both ways."

Nurse Practitioners Educate Patients

For the most part, patients have an added reason to feel comfortable with a nurse practitioner, says Susan Kendig, an attorney and nurse practitioner who coordinates the women's health nurse practitioner program at the University of Missouri at St. Louis.

"One of the things that's important to remember is that we were nurses first," she says. "One of the primary things that we are taught and that we are expected to do and, quite honestly, are graded on is patient education -- learning how to work with people, learning how to watch patient cues so that you can figure out that, while you may be here for a regular exam, you seem really stressed."

While some doctors might focus only on the stated reason for the patient's visit, a nurse practitioner might go further by chatting with the patient about the perceived stress, Kendig says.

"That's the key to it, the fact that we're bringing that background as nurses into that primary-care picture," she says.

She says studies show that patients have good experiences with nurse practitioners.

"They like us. They tend to say that we're better at helping them understand what they are supposed to do to stay well and because of that, they are more likely to do it."

Her specialty as an nurse practitioner has been women's health, providing care through home visits, schools and community agencies. In addition to delivering services, ranging from improving prenatal care to preventing osteoporosis, she says, "I could help them leverage resources in the community that were so important to them in staying well. Being a nurse practitioner helped me bring everything I was passionate about together." (Gov. Jay Nixon recently appointed her to a state board to address prenatal care.)

Nurse Practitioners Complement What Physicians Do

Would it make sense, then, to put a nurse practitioner in every doctor's office?

"We like to think so," Kendig says, adding that she has lots of respect for what doctors do. "More physicians are beginning to see that it's really not replacing the physician but working with the physician because it takes a team approach to get people as healthy as possible, to manage disease and keep it in control."

One big bottleneck in the delivery of care, she says, is fragmentation of services. It occurs because a lot of information is lost as patients move from one part of care to another. Nurse practitioners can address the disconnect between people providing different levels of service to a patient. This is true, she says, "because we are already educated to help manage the care, help the patient go to the right place, help them navigate the system so there is better coordination of the care. That's part of nursing education."

Restrictions Cause Concern

She and other nurse practitioners also are concerned about barriers to doing things they were trained to do. The Institute of Medicine took up this issue in its report, calling on states and federal boards to remove restrictions that prevent advanced practice RNs and others "from practicing to the full extent of their education and training." Barriers in Missouri, says the MNA, include the requirement that nurse practitioners coordinate their work with a physician no farther than 50 miles from the nurse practitioner's practice in rural communities and 30 miles in urban areas. The doctors are required to check or review a nurse practitioner's work every two weeks.

Kliethermes and others say this rule gets in the way of delivering services to rural areas where a doctor might be unavailable within a 50-mile radius of the nurse practitioner's practice. If this were the case in Pilot Grove, Beach's clinic would be out of business. But that's where the folks in Pilot Grove, which is in Cooper County, have been lucky. While not many doctors practice in the county, a few work at Cooper County Memorial Hospital. That presumably makes it easier for Beach to meet the requirement to collaborate with a physician twice a month.

In any case, Kliethermes says, "The miles rule is unnecessary and very arbitrary and restrictive. With mobile communication, we can get in contact with the collaborating physician or whomever we need. It's not as though the physician is going to go back and change the plan of care. A physician could monitor, but there is not any research data showing that this is necessary."

Kendig said that most nurse practitioners are women, probably because most nurses are women and the path to becoming an nurse practitioner is through nursing. She says more men are entering the field.

Like many other former nurses, Kendig cites a variety of reasons for moving up to nurse practitioner or beyond. Earning a law degree, she says, has been valuable in helping her understand the legal framework surrounding health-care policy. She also has been a consultant to companies seeking insight into health issues, including the federal health-reform law.

Others, like Christine Smith, a nurse practitioner at UMSL Health Services, got into the field because of family experiences. She followed the work of her father and brothers who are either firefighters or EMTs in St. Louis.

"I always wanted to go and see what was going on if an ambulance drove by," she says. "In the medical field, there is always room for learning because the field is always changing."

She says her curiosity is more than satisfied these days just by caring for students and faculty who visit the UMSL clinic.

"This work keeps me on my toes."

Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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