In a relatively short period, the role of the advanced practice nurse has been conceptualized and established, evolved into a heavily relied-upon but still supporting position, and, finally today, matured into one of leadership, and growing responsibility. This most recent development has come particularly rapidly, in part accelerated by the creation and proliferation of retail-based convenient care clinics in the last decade. The success of the convenient care clinic industry (retail clinics) has helped to underscore and spotlight the nurse practitioner’s emergence as an independent, front-line provider of first-rate care. Despite these advancements, however, barriers still remain before nurse practitioners can be fully incorporated into the U.S. healthcare delivery system.
Take Care Health Systems (TCHS), which was an early pioneer in the convenient care industry (and was subsequently acquired by Walgreens), prioritized the role of the nurse practitioner from its inception. My role, as Chief Nurse Practitioner Officer for TCHS, was the first of its kind, and helped to set the tone internally as a company that nurse practitioners were critically important to the future success of the business and industry. That notion was carried throughout the corporate hierarchy, and from the very beginning we worked hard to imbue in the nurse practitioners who worked for Take Care a sense of community, leadership, and a capacity to impact their patients’ lives in a positive way on a daily basis. Later, other industry operators followed, creating Chief NP positions in their businesses, with Walmart advancing the NP role to a business owner VP position for their Care Clinics.
Retail clinics came into existence due to disruptive innovation, the goal of which was to help address the issue of a growing lack of access to primary care services. Unique features of this healthcare delivery model included being built from a patient’s point of view, nurse practitioners as the primary provider, an “in-the-neighborhood” community setting in a retail store such as Walgreens and Walmart, and technology leveraged to provide transparency, thereby improving outcomes and ensuring continuity of care.
Today, with over 2,300 clinics nationally and over 30 million patients seen, the retail model and the utilization of nurse practitioners have proven their place in the healthcare delivery system and are becoming more central in discussions with all key stakeholders such as policymakers, insurers, hospital systems, and other healthcare professionals every day. Retail industry founders united (through the formation of the Convenient Care Association) and set standards for quality and safety as well as goals for collaboration with the healthcare community. They insisted on rigorous research into cost, quality, and the patient experience. Analytical powerhouses such as Gallup and RAND Corporation carefully analyzed outcomes.
Results from this research provided empirical evidence that retail clinics were creating a better healthcare experience for patients. Peer-reviewed publications indicated retail clinics offer a quality of care that is as good as or better than many more traditional settings. Multiple published reports looked at retail clinics’ performance relative to the Healthcare Effectiveness Data and Information Set (HEDIS, which is a tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service), and each study showed exceptional adherence to evidence-based guidelines and standards of practice.
This concept of innovation and having impact is one that has been central to the advanced practice nurse profession since its founding. Many of the earliest nurse practitioners came from a background of public health and worked directly in the field, bringing healthcare to those who lacked access to care “by any means necessary.” That focus is still felt today and perfectly exhibited in the convenient care industry. Of the approximately 200,000 nurse practitioners practicing in the U.S. today, well over half maintain a primary care focus. Many work in federally qualified health centers, nurse-managed health centers, retail clinics, and other safety-net providers. Others provide care to rural and underserved communities, in schools, and in the military.
The true potential scope of impact of the advanced practice nurse role, however, is being impeded by longstanding but outdated barriers to practice. Recently, the National Governors Association recommended that states consider changing the scope of practice restrictions in order to fully utilize NPs to their full potential and improve access to care. While many states recognize nurse practitioners as autonomous primary care clinicians and enable them to provide care to the full scope of their education and licensure, many other states maintain restrictions, which ultimately translate into added costs and barriers to patient care. These burdens range from administrative (e.g., requirements related to a percentage of patient charts a collaborating physician must review), to directly practice-related (e.g., limitations on how a nurse practitioner can prescribe medications to a patient), to reimbursement (e.g., not credentialing nurse practitioners as primary care providers). The difficulties are exacerbated in rural areas, where nurse practitioners may not have easy access to the physician collaborators that many states mandate.
A heightened awareness of access to care issues (due in part to the enactment of the Affordable Care Act and continued steps towards implementation of the law) and the ongoing primary care provider shortage across the U.S. has shined a brighter—and more critical—light on these restrictions. Reports like the Institute of Medicine’s Future of Nursing have also supported removal of barriers to NP practice and outdated regulations that limit the ability to practice to the full extent of their education and training and result in barriers to care. State to state, individual regulatory change remains slow, longstanding entrenchment of opposition lingers, and support to override some of these assumptions has not yet reached a tipping point. With that in mind, however, we know that change is coming. Or, as the saying goes, “Change is already here, it’s just not everywhere.”
Many people, nurse practitioners and non-nurses alike, believe advanced practice nurses and related providers, such as physician assistants, are necessarily going to become the front-line primary care providers of the future in the U.S. There aren’t currently enough primary care physicians to go around, the population is graying, and costs of care and the prevalence of chronic disease are rising. There is growing recognition that these healthcare professionals deliver consistently excellent care, and the way we as a public think about and consume healthcare is fundamentally changing. Primary healthcare doesn’t function like it used to because it can’t, and it is time for all of us to respond accordingly to meet the needs of a more consumer driven healthcare experience. Healthcare delivered when and where the patient wants it and how they want it whether it be in person or virtual, the consumer will demand convenience, quality and affordability.
The theory of disruptive innovation teaches us that an established, incumbent industry is susceptible to displacement if it remains unresponsive to changing consumer desires. Traditional medicine is that established industry, currently in the process of being displaced by convenient care clinics, telemedicine, and other novel mechanisms for healthcare delivery. Even the role of pharmacies is changing: Pharmacies, such as Walmart’s, are actively being positioned as points of care for patients and increasing the utilization of pharmacists to more directly support better patient outcomes while working with their retail clinic partners.
Nurse practitioners will remain central to this dialogue of a changing, evolving healthcare environment and convenient care clinics will become both a cornerstone for healthcare services and a resource for consumer education. Founded out of the necessity for a highly skilled healthcare professional who could and would meet patients at the point of care, wherever that may be, the profession of advanced practice nursing has some experience in molding itself to meet shifting demand. By continuing to work towards the ultimate goal of maximizing patient care access, collaboration and improving health outcomes, the future impact of nurse practitioners in the U.S. healthcare delivery system and the convenient care industry knows no limits.