The Emerging Primary Care Workforce

Abstract

Many primary care practices are changing the roles played by the members of their health care teams. The purpose of this article is to describe some of these new roles, using the authors' preliminary observations from 25 site visits to high-performing primary care practices across the United States in 2012-2013. These sites visits, to practices using their workforce creatively, were part of the Robert Wood Johnson Foundation-funded initiative, The Primary Care Team: Learning From Effective Ambulatory Practices.Examples of these new roles that the authors observed on their site visits include medical assistants reviewing patient records before visits to identify care gaps, ordering and administering immunizations using protocols, making outreach calls to patients, leading team huddles, and coaching patients to set self-management goals. The registered nurse role has evolved from an emphasis on triage to a focus on uncomplicated acute care, chronic care management, and hospital-to-home transitions. Behavioral health providers (licensed clinical social workers, psychologists, or licensed counselors) were colocated and integrated within practices and were readily available for immediate consults and brief interventions. Physicians have shifted from lone to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care.An innovative team-based primary care workforce is emerging. Spreading and sustaining these changes will require training both health professionals and nonprofessionals in new ways. Without clinical experiences that model this new team-based care and role models who practice it, trainees will not be prepared to practice as a team.

Utilization of registered nurses in primary care teams: A systematic review

“…In one Australian study, almost 65% of RNs worked in a primary care team with another RN (Pascoe et al, 2005). In contrast, in a study conducted in the US it was typical for one RN to work with four physicians (Ladden et al, 2013). RNs in New Zealand and Spain functioned as a complementary role to the primary care provider during patient visits and the effective utilization of RNs was often dependent on delegation of tasks from the primary care provider (Planas-Campmany et al, 2016, Walker et al, 2015).…”

“…In addition, RNs in Australia, Canada, and the US reported that they performed non-nursing tasks such as billing, filing, booking appointments, restocking equipment, or doing reception duties (Anderson et al, 2012, Pascoe et al, 2005, Phillips et al, 2009, Todd et al, 2007). However, when the primary care team had a medical assistant or nurse’s aide, that were responsible for completing the majority of these organizational tasks, RNs could assume more patient-centered clinical responsibilities (Ladden et al, 2013, Walker et al, 2015). …”

“…Hypertension and diabetes were the two most common chronic diseases for which care RNs were responsible for assessing, monitoring, and following up with patients (Anderson et al, 2012, Joyce and Piterman, 2011, Ladden et al, 2013, Lukewich et al, 2014, Pascoe et al, 2005, Planas-Campmany et al, 2016, Smolowitz et al, 2015, Stewart et al, 2015, Todd et al, 2007, Walker et al, 2015). The most frequent clinical tasks performed by RNs to manage these specific chronic diseases included checking blood pressure and vital signs (Joyce and Piterman, 2011, Lukewich et al, 2014, Patterson et al, 1998), performing electrocardiograms (Anderson et al, 2012, Condon et al, 2000, Halcomb et al, 2008, Patterson et al, 1998, Phillips et al, 2009), adjusting insulin dosage (Anderson et al, 2012), completing diabetic foot exams (Anderson et al, 2012, Todd et al, 2007), measuring blood glucose levels (Patterson et al, 1998), and screening for diabetic retinopathy(Anderson et al, 2012).…”

“…In Spain, RN chronic disease management focused on risk assessment; control and monitoring of risk factors. Asthma was the third most common chronic disease that RNs managed (Ladden et al, 2013, Lukewich et al, 2014, Pascoe et al, 2005, Patterson et al, 1998, Phillips et al, 2009, Walsh et al, 2015). More specifically, in Australia and Canada, RNs assessed asthma control with spirometry or peak flow testing (Condon et al, 2000, Halcomb et al, 2008, Lukewich et al, 2014, Patterson et al, 1998, Phillips et al, 2009), administered nebulizer treatments (Pascoe et al, 2005, Patterson et al, 1998), and provided asthma education (Lukewich et al, 2014, Pascoe et al, 2005, Patterson et al, 1998).…”

“…Today registered nurses (RN) are increasingly embedded into interprofessional primary care teams (Ladden et al, 2013). The integration of nurses into primary care teams shows a promise for enhanced patient care and improved clinical outcomes (Condon et al, 2000, Halper, 2009, Holtrop et al, 2008, Proia et al, 2014).…”