Dual-eligible beneficiaries and inadequate access to primary care.

OBJECTIVES: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. STUDY DESIGN: Secondary data analysis using dual-eligible enrollment data and health care workforce data. METHODS: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. RESULTS: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states. CONCLUSIONS: States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

Psychiatric Mental Health Nurse Practitioners Meeting Rural Mental Health Challenges.

OBJECTIVE: To describe the current rural mental health system crisis in the United States and how psychiatric mental health nurse practitioners (PMHNPs) can holistically mitigate this systemic issue. METHOD: Respective to the objective, relevant literature is reviewed. RESULTS: PMHNPs have successfully increased access to care in underserved rural communities by practicing at the fullest extent of their scope without mandated supervision, utilizing telepsychiatry practice, while expanding PMHNP rural mental health education and research to meet and absolve pressing rural mental health challenges. CONCLUSIONS: Current evidence supports that rural mental health care improves when PMHNPs have full scope of practice, utilize telepsychiatry, engage in related scholarly activity, and have formalized education and training for rural health care delivery, which collectively answer the professional and moral call serving the underserved rural population with mental illness.

The essence of nursing in the shifting reality of Israel today.

Israel's healthcare system is undergoing constant transformation; nurses' roles and education are changing accordingly. Israel's severe shortage of physicians has led to an increase in nurses' authority and responsibilities. The nursing profession is addressing many questions particularly in light of its expanded responsibilities and the current lack of legislation related to the practice of nursing. Additionally Israel is coping with an increasing shortage of nurses and the rapid development of innovative technologies. This article describes Israel's shifting reality and the nation's responses to these changing conditions. Responses include increasing financial support, enhancing educational opportunities, expanding the nursing role, and using new technologies.

Current and projected workforce of nonphysician clinicians.

Nonphysician clinicians (NPCs) are becoming increasingly prominent as health care providers. This study examines 10 such disciplines: nurse practitioners (NPs), physician assistants (PAs), nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists, and clinical nurse specialists. The aggregate number of NPCs graduating annually in these 10 disciplines doubled between 1992 and 1997, and a further increment of 20% is projected for 2001. Assuming that enrollments remain at the levels attained in 2001, NPC supply will grow from 228000 in 1995 to 384000 in 2005, and it will continue to expand at a similar rate thereafter. The greatest growth is projected among those NPCs who provide primary care services. Moreover, the greatest concentrations of both practicing NPCs and NPC training programs are in those states that already have the greatest abundance of physicians. On a per capita basis, the projected growth in NPC supply between 1995 and 2005 will be double that of physicians. Because of the existing training pipeline, it is probable that most of the growth projected for 2005 will occur. The further expansion of both NPC and physician supply thereafter warrants careful reconsideration.

Beyond the clinic: redefining hospital ambulatory care.

Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff for practicing in a managed care environment, and help staff communicate with a culturally diverse patient population and promote the importance of primary care within the community. Significant innovations and improvements were realized through the projects. Several hospitals expanded the availability of primary care services, trained new primary care providers, and helped patients gain access to primary care clinicians for the first time. Better methods for documenting ambulatory care were introduced. To increase efficiency and improve service to patients, some of the hospitals instituted automated appointment systems and improved medical record services. To reduce fragmentation and contain personnel costs, support staff positions were redesigned, and staff were retrained to carry out new multi-tasked responsibilities. Many of the components vital to high-quality ambulatory care can take years to develop, and significant investments of capital. Increased primary care capacity, new specialty group practices, state-of-the-art equipment for diagnosis and treatment, advanced information technology to manage and coordinate care and link services at multiple locations, and highly trained clinical and support staff all require strong commitment and support from a team of senior management executives and medical staff leaders, sufficient staffing resources, and outside expertise. Once the infrastructure is in place, hospitals must continue to reach out to their communities, helping people to understand the health care system and use it effectively.

A proposal for a men's health nurse practitioner.

The educational preparation of a men's health nurse practitioner (MHNP) is proposed. The MHNP's scope of practice would address the complex health needs of men from a holistic perspective with emphasis on the knowledge and skills necessary for providing comprehensive primary care. Need for the MHNP is discussed, and scope of practice is delineated. Conclusions are drawn regarding the future of the MHNP in the scheme of total health care.

Nurse practitioners in Ghana: a follow up.

PIP: An earlier paper described the training of enrolled nurses for work as nurse practitioners in Berekum. Many mission hospitals have availed themselves of this training, and have given continuous support to these young nurses. Patients have had to wait less time for attention; medical staff have been able to finish their outpatient clinics at about noon, instead of 5 pm; laboratory and pharmacy staff have also profited. There have been several new developments. A number of trained and experienced male nurses have begun to work in village clinics. Most of them were invited to do so by the chiefs and people of these villages. The District Medical Officer (a Medical Mission Sister) helped the nurses with advice, medicines and provisions as needed and also recommended them to the Regional Ministry of Health in Sunyani, for official approval. The District Medical Officer visits the clinics at intervals, and keeps close contact with the nurses through the system of referrals. Patients are sent to Holy Family Hospital with a letter, stating the complaints and the treatment given in the clinic. These letters are returned with the doctor's findings, the treatment given, the end result, and the further care which may still be needed. Thus each referral constitutes a learning experience, which is showing good results in the work of the nurses. The beginning of a primary health care system has been created. Numerous well-baby clinics have grown up around the curative centers. Midwives practising in private maternity homes in the villages of this district have voluntarily joined the project. Such midwives are all capable and experienced professionals; they must have 5 years of practice before the government will allow them to set up a private maternity home. They attend annual seminars. These midwives carry a heavy responsibility, since maternal mortality is high. Student midwives now receive a course of lectures on the care of women of child-bearing age.^ieng

The supply of physicians and physicians' incomes: some projections.

This study identifies trends that will lead to a dramatic increase in the number of active physicians in the United States during the next decade. The supply of active medical doctors (MDs) and doctors of osteopathy (DOs) as well as active post-graduate MDs and DOs in the U.S. is projected to increase by approximately 50 percent in the decade ending in 1985. The number of active physicians per 100,000 population is similarly expected to increase by approximately one-third. The production of surgical specialists, in particular, appears to be excessive. In response, the average length of physician graduate training programs is anticipated to be shortened as more MD and DO graduates enter shorter, general practice residencies. The authors expect that the effects of this projected increase in the supply of physicians may relieve geographic disparities in physician distribution, rationalize the organization of medical practice, and reduce physicians' incomes relative to other professional groups and possibly in absolute terms. The projected increases in the supply of physicians will give the federal government much more flexibility and bargaining power should it choose to implement a national health insurance program with salaried physicians.