Primary prevention of lead exposure: the Philadelphia lead safe homes study.

OBJECTIVE: Lead exposure in children can lead to neuropsychological impairment. This study tested whether primary prevention interventions in the newborn period prevent elevated blood lead levels (BLLs). METHODS: The Philadelphia Lead Safe Homes (LSH) Study offered parental education, home evaluation, and lead remediation to the families of urban newborns. Households were randomized to a standard lead education group or maintenance education group. We conducted home visits at baseline, six months, and 12 months. To compare BLLs, we identified a matched comparison group. RESULTS: We enrolled and randomized 314 newborns in the intervention component; 110 completed the study. There were few significant differences between the randomized groups. In the combined intervention groups, positive results on visual inspection declined from baseline to 12 months (97.0% to 90.6%, p = 0.007). At baseline, 36.9% of homes were above the U.S. Environmental Protection Agency's lead dust standard, compared with 26.9% at 12 months (p = 0.032), mainly due to a drop in windowsill dust levels. Both groups showed a significant increase in parental scores on a lead education test. Children in the intervention and matched control groups had similar geometric mean initial BLLs (2.6 vs. 2.7, p = 0.477), but a significantly higher percentage of children in the intervention group had an initial blood lead screening compared with those in the matched group (88.9% vs. 84.4%, p = 0.032). CONCLUSIONS: A study of primary prevention of lead exposure showed a higher blood lead screening rate for the combined intervention groups and mean BLLs at one year of age not statistically different from the comparison group. Most homes had lead hazards. Lead education significantly increased knowledge.

Convenient care clinics: the future of accessible health care.

The need for accessible, affordable, quality health care in the United States has never been greater. In response to this need, convenient care clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. In CCCs, highly qualified health care providers diagnose and treat common health problems, triage patients to the appropriate level of care, advocate for a medical home for all patients, and reduce unnecessary visits to emergency rooms and Urgent Care Clinics. CCCs have been called a "disruptive innovation" because they are consumer driven. They serve as a response to many patients who are unhappy with the current conventional health care delivery system--a system that is challenged to provide access to basic health care services when people need it the most. CCCs are based in retail stores and pharmacies. They are primarily staffed by nurse practitioners (NPs). Some CCCs are staffed by physician assistants (PAs) and physicians. The authors acknowledge the important roles of both PAs and physicians in CCCs; however, this paper primarily provides education about the role of NPs in CCCs. CCCs have evolved at a time when our health care system is floundering, and the need for accessible, affordable health care is at its greatest. The CCC model provides an accessible, affordable entry point into the health care system for those who previously were restricted access.

Insurer policies create barriers to health care access and consumer choice.

A national survey shows that most insurance companies refuse to credential nurse practitioners in nurse-managed health centers as primary care providers. These prohibitive policies along with weak federal and state laws threaten the long-term sustainability of nurse-managed health centers as safety net health care providers, and the ability for nurse practitioners to become an accepted primary health care source in the United States.

The nurse-managed health center safety net: a policy solution to reducing health disparities.

Nurse-managed health centers are critical safety net providers. Increasing support of these centers is a promising strategy for the federal government to reduce health disparities. To continue as safety net providers, nurse-managed health centers need to receive equal compensation as other federally funded providers. Ultimately, the long-term sustainability of nurse-managed centers rests on prospective payments or similar federally mandated funding mechanisms.

Are managed care organizations in the United States impeding the delivery of primary care by nurse practitioners? A 2012 update on managed care organization credentialing and reimbursement practices.

In 2014, the Affordable Care Act will create an estimated 16 million newly insured people. Coupled with an estimated shortage of over 60,000 primary care physicians, the country's public health care system will be at a challenging crossroads, as there will be more patients waiting to see fewer doctors. Nurse practitioners (NPs) can help to ease this crisis. NPs are health care professionals with the capability to provide important and critical access to primary care, particularly for vulnerable populations. However, despite convincing data about the quality of care provided by NPs, many managed care organizations (MCOs) across the country do not credential NPs as primary care providers, limiting the ability of NPs to be reimbursed by private insurers. To assess current credentialing practices of health plans across the United States, a brief telephone survey was administered to 258 of the largest health maintenance organizations (HMOs) in the United States, operated by 98 different MCOs. Results indicated that 74% of these HMOs currently credential NPs as primary care providers. Although this represents progress over prior assessments, findings suggest that just over one fourth of major HMOs still do not recognize NPs as primary care providers. Given the documented shortage of primary care physicians in low-income communities in the United States, these credentialing policies continue to diminish the ability of NPs to deliver primary care to vulnerable populations. Furthermore, these policies could negatively impact access to care for thousands of newly insured Americans who will be seeking a primary care provider in 2014.

Primary prevention of lead exposure--blood lead results at age two years.

OBJECTIVES: The Philadelphia Lead Safe Homes (LSH) Study was designed to evaluate whether educational and environmental interventions in the first year of life for families of newborns increased knowledge of lead exposure prevention and were associated with less elevation of blood lead levels (BLLs) for these children, when compared to children receiving standard care. METHODS: The current study performed descriptive statistics on the second-year BLL data for both groups and compared these using chi-square tests for proportions and unpaired t-tests for means. RESULTS: A BLL result was found for 159 (50.6%) of the 314 LSH cohort children and 331 (52.7%) of the 628 control children (p = 0.1). Mean and standard deviation for age at draw was 23.8 (3.4) months versus 23.6 (3.1) months (P = 0.6). Geometric mean BLLs were 3.7 versus 3.5 µg/dL (P = 0.4). The percentages of the cohort group with a BLL of ≥ 20, ≥ 10 and ≥ 5 µg/dL, respectively, were 0.6%, 5% and 30%; for the controls 1.2%, 6.6%, and 25%. These percentages were not significantly different between groups. CONCLUSION: A comparison of geometric mean BLLs and percentages above several BLL cut points drawn at age two years in a group of urban newborns benefitting from study interventions versus a group of similar urban children did not yield statistically significant differences. Both groups had relatively lower lead levels when compared to historical cohort groups, which may reflect a continuing downward trend in BLLs in U.S. children. The interventions did result in benefits to the families such as an increase in parental knowledge about lead exposure prevention and in-home wet cleaning activity, and a decrease in lead dust levels in study homes.

Developing alliances: how advanced practice nurses became part of the prescription for Pennsylvania.

The authors describe how advanced practice nurses in Pennsylvania were able to successfully advocate for nursing-related legislative reforms through Governor Edward G. Rendell's signature health care reform plan (the "Prescription for Pennsylvania"). In addition to discussing advocacy efforts related to a series of nursing-related bills considered by the Pennsylvania Assembly in 2007, the article also describes years of hard work and foundational advocacy conducted by a broad coalition of nurses, which paved the way for the Prescription for Pennsylvania's reforms. By examining the successful tactics of Pennsylvania's nurse advocates, the authors conclude that policy makers' current interest in solving the health care crisis presents a tremendous opportunity for nurses to reform legislation. To seize this opportunity, nurses must learn to speak with a unified voice and build strong relationships with a broad range of bipartisan policy makers, funders, civic leaders, business leaders, and legislative advocates.

Convenient care clinics: the future of accessible health care--the formation years 2006-2008.

In the 2 years since the Convenient Care Association (CCA), a nonprofit organization representing the members of the Convenient Care industry, was founded, this new model has gained significant traction in the health care marketplace and in the awareness of health care consumers. When the CCA was formed, fewer than 200 clinics were in operation. Now, there are more than 1000 clinics seeing patients, and more than 3.5 million patient visits have been recorded across the country. As the industry has expanded, some challenges have arisen, mostly in the form of legislative and regulatory initiatives aimed at impeding clinic operation. The CCA and its members continue to undertake substantial efforts to build comprehensive quality processes into the convenient care model. The effect of these measures has been to mitigate the allegations of poor quality and inconsistent care that have been levied against the clinics. The media and public responses have been generally positive, and policy makers and other decision makers have been receptive to the benefits convenient care can offer to their constituents.

Insurers' contracting policies on nurse practitioners as primary care providers: two years later.

A national survey showed that nearly half of all major managed care organizations in the United States refuse to credential nurse practitioners as primary care providers. In nurse-managed health centers throughout the country, nurse practitioners provide primary care to underserved populations with similar outcomes to primary care physicians. Insurers' prohibitive credentialing and reimbursement policies reduce these centers' capacity for growth and, in turn, threaten the long-term sustainability of a key component of the health care safety net. Two years after conducting a national survey of insurers' credentialing and reimbursement policies regarding primary care nurse practitioners, researchers returned to the subject matter and found that many of the same financial barriers to nurse-managed health center sustainability still exist. Although some progress had been made since 2005, this progress did not appear to be attributable to regulatory changes or renewed enforcement of existing laws.

Insurers' contracting policies on nurse practitioners as primary care providers: the current landscape and what needs to change.

A national survey showed that most insurance companies refuse to credential nurse practitioners as primary care providers in nurse-managed health centers. These prohibitive policies, along with weak federal and state laws, threaten the long-term sustainability of nurse-managed health centers as safety-net health care providers and limit the ability for nurse practitioners to become an accepted primary health care source in the United States. Interviews with national managed care organizations revealed that these companies' current business practice and policies are unlikely to change without regulatory change at state and/or federal levels.