VA Testimony of Robert Petzel, MD before Congress on June 14, 2001

United States Department of Veterans Affairs

STATEMENT OF
ROBERT PETZEL, MD, NETWORK DIRECTOR
VA UPPER MIDWEST HEALTH CARE NETWORK
DEPARTMENT OF VETERANS AFFAIRS

BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
WITH RESPECT TO
NURSING WORKFORCE STRATEGIES INNOVATION PANEL AND NURSE MANAGED PRIMARY CARE DELIVERY CLINICS

June 14, 2001

MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE:

I appreciate the Committee's invitation to participate in this very timely hearing on nursing workforce strategies.

For today's hearing, I am going to discuss primary care clinics run by nurse practitioners in the U.S. Department of Veterans Affairs Upper Midwest Health Care Network, in the states of Minnesota, North Dakota, and South Dakota.

Health care presently is an ever-changing environment for all Americans, including the veteran population. New and innovative approaches to health care must include goals that maximize quality care, improve access and cost effectiveness, facilitate patient satisfaction, and optimize the functional status of patients. Recognizing the opportunities in this challenging environment, nurse practitioners are being effectively utilized as competent primary care providers who can meet these goals.

In an effort to improve access, nurse-managed primary care delivery clinics were established in 1999 across the VA Upper Midwest Health Care Network. These community-based outpatient clinics ( CBOCs) use nurse practitioners as independent practitioners with prescriptive authority. To qualify as a nurse-managed clinic in our Network, the following criteria must be met: (1) a Masters degree-prepared advanced practice nurse with national certification as a primary care provider; (2) a qualified registered nurse as a case manager on site; (3) credentialing and privileging in place that includes prescribing authority; (4) provisions in place for ancillary help and access to medical records, laboratory, pharmacy, and radiology services; (5) establish outcomes research in the future; (6) establish academic partnerships.

The four clinic sites include Chippewa Valley, Wisconsin; Grafton, North Dakota; Fergus Falls and Maplewood, Minnesota. Staff at each site includes a nurse practitioner, a registered nurse, and a clerk with total FTE ranging from 4 - 6.5 FTE. Some sites also have a licensed practical nurse. Panel sizes for the nurse practitioners range from 600 to 1,100 patients.

Evaluation of the program outcomes includes market penetration, patient satisfaction, financial analysis, clinical indicators, and workload analysis. These clinics have enrolled and are providing primary care to an average of 1,000 veterans, most of whom are new to the VA system. Patient satisfaction survey results are excellent; patients appreciate the availability of these clinics in their communities and are complimentary of the care they receive. For example, when a nurse practitioner from the Minneapolis VA Medical Center transferred to the Maplewood clinic, a number of her patients requested to move with her; this certainly demonstrates a high level of satisfaction when a patient changes their site of care to remain with their provider. It is also important to note availability of appointments. Even though the nurse practitioner at the Grafton clinic has a panel size of 1,100, a patient can be seen within 48 hours of a requested appointment. Prevention and chronic disease index ratings and clinical practice guideline implementation in these nurse managed primary care delivery clinics are consistent with the other primary care clinics at the host VA medical centers in VISN 13. In fact, the nurse practitioners strive to meet the indicators and place greater emphasis on patient education. Cost per visit at the clinics range from $98.00 (Chippewa Valley) to $140.00 (Maplewood) as compared to $137.00 per visit at the host Minneapolis VA Medical Center and $102.00 (Fergus Falls) to $108.00 (Grafton) as compared to $162.00 per visit at the host Fargo VA Medical Center.

The following case is just one example of the care individuals receive when they come to a nurse managed clinic in our Network. Mr. K. is a 87-year-old veteran who has been receiving care at the Fergus Falls Clinic since April, 1999. He has a history of chronic obstructive pulmonary disease, prostatic carcinoma, valvular heart disease, and congestive heart failure. He cares for his wife who has been blind for many years. Initially he came to the clinic for daily dressing changes to a leg ulcer. The nurse at the clinic arranged for a community health nurse to change his dressings on the weekends. However, during his visits to the clinic for the dressing changes, he was noted to be more short of breath with activity, ankle swelling, and have a hemoglobin of 7.7. He was given a blood transfusion and medications were adjusted. As stated by Donna Hendel, R.N., nurse at the clinic, "I am convinced Peggy (the Nurse Practitioner at the Clinic) has been responsible for preventing at least one hospitalization so far." As a result of the interventions of the staff at the Clinic, Mr. K. is able to remain in his home, caring for his wife, and is able to travel to Fergus Falls rather than having to come to Fargo, a distance of 65 miles, for his care.

In summary, the world of health care is in transformation. Demands for higher quality, greater accountability, and lower costs are currently driving the system. Nurse practitioners are effective as providers of safe, high-quality, cost-effective primary care, which results in high patient satisfaction. Additionally, patients generally select a provider whom they feel will listen and address their needs; nurse practitioners have a history of providing patient-focused care. Therefore, it made sense to move forward with the establishment of nurse managed primary care delivery clinics throughout our Network. However, our work is not done. We must now demonstrate in terms of outcomes-based research the services that nurse practitioners provide and their positive impact on client outcomes.

This concludes my remarks. I will be pleased to respond to any questions you may have.