Empowering, energizing and exhausting are terms sometimes used by family nurse practitioners Tim Rausch and Ricky Norwood to describe work with underserved populations. Both agree it is also rewarding.
Rausch, RN, MSN, FNP, sees patients at the UCLA School of Nursing Health Center at the Union Rescue Mission in downtown Los Angeles. He provides primary care for patients who often are homeless. Presenting with an acute need such as an abscess, the flu or a headache, his exams often reveal patients have undiagnosed chronic diseases. “They might have hypertension with a pressure over 200 [systolic], or blood glucose above 400,” Norwood said.
Most clients, he said, also have mental health or substance abuse concerns. Poor health literacy often adds to the issues these clients face.
While some patients return for chronic disease management, he said others never come back. Averaging 15 patients a day, Rausch performs well-child exams and screenings along with adult care.
The patient base is somewhat similar at the Sacramento County Health Center where Norwood, DNP, MSN, RN, FNP-BC, sees patients. The county clinic is associated with the Betty Irene Moore School of Nursing at UC Davis in Sacramento through a first-of-its-kind cooperative agreement. As an assistant clinical professor with the SON, Norwood works in the clinic’s new Healthy Partners program. The program, according to the county’s health and human services website, provides primary and preventive healthcare to low-income, undocumented adults residing in Sacramento County.
Long, but rewarding days
“We work very long, but rewarding days,” Norwood said. “I come in energized and leave exhausted.” He said 80% of patients have never had healthcare, so he performs a thorough history and physical exam, then proceeds with care based on the findings. Most patients are Hispanic, require an interpreter, and common findings include diabetes, hypertension and thyroid disease.
Norwood said he takes true pleasure in this work, because as a child growing up in Mississippi, he had no healthcare access. “I understand these patients’ need and issues,” Norwood said. Likewise, Rausch, a former ICU and critical care nurse, chose to specialize in primary care for underserved populations because he believes it helps prevent hospitalization, and even disability and death for many of his patients.
He first sampled the work as an NP student on rotation and is convinced it’s an exceptional experience for NP students. “Students very quickly become immersed in the social determinants of health,” Rausch said. “Instead of learning about lab values and diagnoses, they’re learning what got these patients to where they are and how that impacts [the patients’] health. Students learn how to develop strategies for patients that empower them to take control of their health, It’s a unique kind of experience.”
Norwood, who will begin precepting NP students at the Sacramento clinic this summer, agrees. “You can’t get a better model of care than this,” he said. “It’s totally holistic care.”
Skills required to serve the underserved
Success in treating underserved populations demands energy and top skills, both NPs assert. Rausch said a natural affinity toward patient education is also valuable.
“So many of the issues involved with poor health in this population are due to poor health literacy,” Rausch said. “As we give them the knowledge they need about their conditions, and encourage them to return for follow-up care, we can prevent really bad outcomes that will land them in the ER or a hospital.”
Being creative and committed to find a way to connect with each patient and develop a relationship is also necessary.
Norwood added, “If you want a job that will challenge you on a daily basis, give you an opportunity to lift up others and give back, you’ll never have a dull moment. You’re rocking and rolling from the time you start until you leave.”
The investment of skills and patient connection pays off, according to Rasuch. “In the end, it’s rewarding to know that we are helping the patients who otherwise may not be receiving care,” Rausch said
Thousands of communities throughout the United States have been identified by the Department of Health and Human Services (HHS) as underserved. Given the designation of a health professional shortage area (HPSA), medically underserved area (MUA), or medically underserved population (MUP), the communities and their individual members struggle to address health care needs. The designations given by HHS generally mean that there are not a sufficient number of primary, mental, or dental health care workers to meet the demands for services.
The patients in these communities, often in rural areas or inner-cities, face a number of challenges due to the understaffed health care system in their immediate location. Among these challenges are longer wait times for appointments, longer travel to access care, or delayed and ignored care. The understaffing of the health care system also puts a strain on providers in these locations. Providers are often required to see more patients than their colleagues from non-underserved communities and the acuity of the patients they do see is often higher.
So how do you bring value to a health care system in these communities? How do you advance responsive care, preventative care, and low-cost care in areas that face so many significant challenges? The federal government has established a number of programs aimed at encouraging current Medicare providers to practice in underserved communities. From Area Health Education Centers and Teaching Health Center programs to the National Health Service Corps, the federal government has increased investment in training and placement programs that will help direct providers to the communities in most need.
But the resources for these programs are limited. Medicare providers cannot be forced into these communities. And these programs do not directly address the questions of value in providing health care to the underserved.
However, one group is working to use current health care practitioners to help fill gaps in underserved communities. The Patient Access to Pharmacists’ Care Coalition (PAPCC), advised by Leavitt Partners, is advancing legislation that would authorize Medicare payment for clinical services provided by pharmacists, pursuant to state scope-of-practice law, in medically underserved communities. Pharmacists are already well-trained and on the ground in underserved communities, willing and able to provide vital care to those in need. As part of the health care team, they provide a number of services, including conducting health and wellness testing, helping patients manage chronic conditions, administering immunizations, and helping patients understand and manage their medications. The legislation advanced would compensate for these important services and enhance access for millions of underserved Americans.
Not only would the proposal provide access to care for many underserved seniors, it would bring value to health care by allowing pharmacists to practice at the top of their license, and enabling access to many clinical services. Patients would benefit from accessing local, timely care from a provider that they already know. They would be less likely to delay care and timely interventions could be made. Additionally, pharmacists, as part of a patient’s health care team, can work with individual patients to reduce hospital readmissions, increase medication adherence, and improve outcomes.
Pharmacists and pharmacies also help local health care dollars stay in the community. For rural and underserved urban populations, strengthening the local economy is an important part of the value discussion.
While not a panacea for all the health care needs in underserved communities, pharmacists and pharmacies are an important, and currently underutilized, component in the health care system. By advancing the PAPCC proposal, millions of Americans will see increased access to care, closer to their homes, with a high likelihood for better outcomes.