Surgeon General’s Call to Action: Community Health and Prosperity

Nov 05, 2018

Dear Mr. Vincent:

The National Nurse-Led Care Consortium (NNCC) appreciates the opportunity to comment on the Surgeon General’s Call to Action: ‘‘Community Health and Prosperity.’’

Investing in community can create health and prosperity. NNCC has been fortunate to work with diverse funders that have supported two nurse-led community health models that bolster the health and well-being of Americans:

  • Nurse-managed health clinics improve the health of rural, suburban, and urban communities while providing educational opportunities for the next generation of the healthcare workforce.
  • Nurse home visiting is a cost-effective way to increase children’s school readiness and improve family economic self-sufficiency.

ORGANIZATIONAL BACKGROUND AND CONTEXT FOR COMMENTS

NNCC Represents Nurse Leaders Providing Community-Based Healthcare Throughout the Nation

NNCC is a 501(c)(3) nonprofit public health organization that seeks to advance all forms of nurse-led care through policy development, technical assistance, and innovative programming. NNCC is an affiliate of Public Health Management Corporation, the public health institute for Pennsylvania and Delaware, which provides a variety of public health and social services to address the community needs in the Philadelphia and surrounding region.

The nurse-led care philosophy puts patients at the center of care and identifies the social determinants of health to treat people, not symptoms. Nurses are the most trusted profession in the United States, because their training gives them the tools to care for the whole patient, prevent problems before they arise, and deliver high-quality, affordable care to the people who need it most. NNCC’s goal is to support and empower nurses to improve care, lower costs, and take on leadership roles that advance systems change.

NNCC Provides Training and Technical Assistance to Nurse-Led Community Health Providers

NNCC partners with the American Association of Nurse Practitioners to administer the Nurse Practitioner Support and Alignment Network for the Transforming Clinical Practice Initiative through the Centers for Medicare and Medicaid Services. The project has reached over 40,000 nurse practitioners working in diverse healthcare practices to enhance quality and optimize workflow that improves the patient experience and increases efficiency. The training program helps enable nurse practitioners delivering care to the community to navigate an evolving reimbursement landscape and cultivate high-quality and sustainable clinical practices.

NNCC also holds a National Cooperative Agreement with the Health Resources and Services Administration to provide technical assistance to federally qualified health centers (FQHCs) that serve residents of public housing. NNCC works directly with clinics designing and scaling interventions to address social determinants of health, chronic diseases, and behavioral health. NNCC learns directly from nurse-led health settings about the challenges impacting their communities and helps implement best practices to meet health and wellbeing needs.

NNCC Launches and Sustains Nurse-Led Innovations That Improve Health and Support Vulnerable Families in a Cost-Effective Way

From its home office in Philadelphia, NNCC builds programs to serve as national models for public health nursing in action. Two of NNCC’s most successful programs are Philadelphia Nurse-Family Partnership (Philadelphia NFP) and the Mabel Morris Family Home Visit Program (MM-PAT), evidence-based early childhood initiatives serving low-income women and children. Philadelphia NFP implements the national Nurse-Family Partnership (NFP) home visiting model, while Mabel Morris employs the Parents As Teachers (PAT) curriculum.

NNCC has led the Philadelphia NFP program since 2004, and the complementary MM-PAT program since 2010. The collective program goals include: better pregnancy outcomes; improved child health and development; increased school readiness; and greater economic self-sufficiency for families. Since inception, Philadelphia NFP and MM-PAT have served over 4,800 families.

COMMENTS

1) Nurse-managed health clinics improve the health of rural, suburban, and urban communities while providing educational opportunities for the next generation of the healthcare workforce.

Nurse-led clinical practices represent, by their very existence, an innovative expansion in delivery of, and access to, healthcare services. Nurse leaders have been early adopters of transformative clinical practices, such as patient-centered care, behavioral health integration, and more. NNCC works to develop a next generation of nurse leaders to transform the delivery of healthcare.

In addition to other nurse-led practice models, NNCC represents nurse-managed health clinics. Section 254c-1a of the Public Health Service Act defines a nurse-managed health clinic as a “nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center (FQHC), or independent nonprofit health or social services agency.”

Nurse-led clinics accounted for 587 FQHCs in 2017. In these clinics, healthcare is directed or co-directed by nurse practitioners and/or other advanced practice nurses offering a wide range of primary care, health promotion, and disease prevention services to patients. According to the Uniform Data System, nurse practitioners in these 587 health centers recorded approximately 10.4 million patient visits in 2017. Yet FQHCs account for only a portion of the nurse-led health settings that are bringing resources into communities to improve health and prosperity.

Nurse-managed health clinics often focus on underserved communities and partner with their community to provide quality and affordable healthcare. Many nurse-managed health clinics are located in places that have traditionally lacked access to quality healthcare, including public housing, urban and rural communities, older adult centers, elementary schools, storefronts, and places of worship. Because nurse-managed health clinics are often created where there is need, funding has come from the philanthropic sector to help address that need. Their funding mix varies, but typically includes investments from private donors (including private foundations) along with government and private insurer reimbursement.

Many nurse-managed health clinics are affiliated with schools and colleges of nursing, and therefore also help to build the capacity of the nation’s healthcare workforce by acting as teaching and practice sites for nursing students and other health professionals. Each academically-affiliated nurse-managed health clinic provides clinical placements for an average of 50 to 60 students a year. These students include graduate and undergraduate nursing students, as well as medical, physician assistant, and social work students, among others.

They are intimately connected to the developing healthcare workforce and thus provide a pipeline for healthcare access, educational advancement, and employment opportunities. Nurse-managed health clinics represent an innovative model to provide healthcare to support community well-being with the support of private sector investment.

2) Nurse home visiting is a cost-effective way to increase children’s school readiness and improve family economic self-sufficiency.

NNCC manages the Philadelphia Nurse-Family Partnership (Philadelphia NFP) and the Mabel Morris Family Home Visit Program (MM-Parents as Teachers), evidence-based early childhood initiatives that provide home visiting, family support, and education to low-income mothers of young children throughout the City of Philadelphia. Philadelphia NFP serves low-income first-time mothers and their babies until age 2. MM-PAT complements Philadelphia NFP by supporting families with young children from birth until age 5, using the Parents as Teachers (PAT) model.

Both the NFP and PAT models have been the subject of rigorous research and meet the criteria set forth by the U.S. Department of Health and Human Services (HHS) for evidence-based early childhood home visiting programs. Both programs are premised on the understanding that pregnant women and new mothers are more receptive to receiving services and making positive changes at this crucial point than at any other time in their lives. Moreover, the skills developed at this time will set patterns for the future.

Both Philadelphia NFP and MM-PAT provide parental education and support through an established curriculum that focuses on topics such as child development, maternal-child health, and positive parenting practices. The programs also work with mothers to set goals related to their own education and employment, and break the cycle of intergenerational poverty.

MM-PAT was originally launched in response to community needs, as nurses saw that the extremely high-risk client population served by Philadelphia NFP could benefit from additional support and counseling during their children’s toddler and preschool years, and even during subsequent pregnancies. NNCC’s nurse-driven integration of NFP and PAT offers greater continuity and support for families than can be provided by a stand-alone program. This innovative combination of two evidence-based programs is especially impactful in Philadelphia, where intergenerational poverty is widespread and clients often present with complex social needs that endure beyond the first two years of a child’s life. Approximately 40% of MM-PAT’s caseload is comprised of Philadelphia NFP graduates. Integrating two evidence-based home visiting programs has allowed NNCC nurses to deliver services more efficiently and effectively to better serve high-risk clients.
Research has demonstrated both the NFP and PAT program models’ proven effectiveness in addressing a wide variety of challenges experienced by low-income families. The exceptional outcomes achieved among both mothers and babies prove that participation in nurse home visiting programs has the potential to change the entire trajectory of families’ lives.

The outcomes for both the PAT and NFP program models indicate enhanced school readiness and family economic self-sufficiency, as well as a variety of health-focused outcomes. Well-designed research has consistently demonstrated the following positive impacts associated with each model:

Nurse-Family Partnership (NFP)

Improvements in:

  • Maternal health;
  • Child health;
  • Child development and school readiness;
  • Reductions in child maltreatment;
  • Reductions in juvenile delinquency, family violence, and crime;
  • Positive parenting practices; and
  • Family economic self-sufficiency

Parent as Teachers (PAT)

Improvements in:

  • Child development and school readiness;
  • Reductions in child maltreatment;
  • Positive parenting practices; and
  • Family economic self-sufficiency

Recent peer-reviewed research reiterates the positive, long-term impact that evidence-based nurse home visiting has on vulnerable families. A 2017 study that followed NFP families in Memphis until their children turned 12 years old found that the NFP intervention had an especially positive impact on boys, lasting into adolescence. Children enrolled in NFP experienced cognitive gains as compared to their peers. This effect was attributed to both health improvements during the prenatal/perinatal stage, as well as long-term effects of better parent-child attachment and lower maternal stress.

Because of proven positive results like these, it is projected that every dollar invested in NFP yields $6.40 in return to society, and $2.90 in savings to state and federal governments.

Like most home visiting programs nationwide, NNCC’s home visiting programs are funded through a mix of investments from private donors (including private foundations, corporate donors and the United Way), along with state and federal funding.

CONCLUSION

Nurses provide community-based care and lead innovation in a variety of contexts nationwide. Nurses are essential to developing cost-effective, value-based solutions to improving community health. Nursing’s knowledge, expertise, and holistic approach to patient care are essential to building a better healthcare system in the future that meets the needs of the current and emerging workforce. The models described in this comment have garnered support from individual, corporate, and other philanthropy in addition to effectively and efficiently leverage public support where appropriate.

Thank you for the opportunity to provide comments on how investments in community health can enhance wellbeing and economic prosperity. If you or your colleagues would like additional information, or would like to visit our offices in Philadelphia, please feel free to contact me at  or 215-731-7148. We would welcome the opportunity to introduce you to the dedicated nurses on our staff and the families we serve.

Sincerely,
Sarah Hexem Hubbard, Esq.
Executive Director

Submitted via: http://www.regulations.gov

Re: Docket Number CDC–2018–0082

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