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OCR for page 234
Partnership for Heath:
The Family Nurse
Practitioner/Family
Physician Team
Mo~ry O'Hare Detereo`ax
Community oriented primary care (COPC) suggests a broad, comprehen-
sive care package to communities, families, and individuals that demands
more than a strictly medical problem-solving approach. A look at the current
approaches to primary care in the United States with their narrow focus,
physician dependency, predominance of low-risk cases, illness orientation,
valuable management quality, and sense of competition with other care-
givers in the community points to the need for new organizational models
if true COPC is to exist. The elements of a new organizational model for
COPC are listed in Table 1.
Implicit in this list is the need for a system rather than an isolated,
individualized, traditional approach. Such a regional, experimental system
of COPC has been developed by the Foundation for Comprehensive Health
Services in California. The foundation is a public, nonprofit organization
with a broad-based and experienced Board of Directors who provide profes-
sional leadership. Community advisory groups are available tO the practices
within the organized delivery system. The administration of the system is
both centralized and decentralized, with a professional staff that travels to
the practices to provide on-site training and expertise. The foundation
provides not only direct service, but is also involved in research, education,
and consultative services.
The foundation systems have a broad focus that is community and patient
oriented to provide services in the wellness/illness continuum. Although
the foundation strives for permanent provider employees, the system and
each site is not dependent on a particular physician. This system allows the
234
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Partnership for Health
235
flexibility to experiment with different programs, provider mix, and rela-
tionships with other community services. These programs are initially sup-
ported with excess dollars generated in the system and reinvested in primary
care rather than invested in an institution of secondary or tertiary care
technology. This primary care focus and investment program strengthens
the primary care base and improves patient health care. Central to success
is humanistic but sound management. This model is not proposed as a
universal solution to problems of medical care or organization, but it does
offer some workable solutions to the delivery of COPC.
Within the foundation's organized system of COPC, a critical decision
surfaced who and what kinds of providers will staff such a program. After
preliminary research, the family practice team was chosen (a family physician
and a family nurse practitioner) as the most effective, efficient model. Through
case studies of foundation practices, followed by a large-scale study of 230
practices throughout California, certain conclusions emerged regarding the
best team model and the advantages of the family practice team model
versus the physician-only model. The family physician/family nurse prac-
titioner team has the ability to deliver a broad spectrum of COPC. The
most effective and efficient relationship for the team is a collaborative
approach that transcends and is significantly different from the traditional
doctor/nurse relationship. The elements of a successful, collaborative prac-
tice resulting in a broad spectrum of COPC are listed in Table 2.
The collaborative practice model allows each practice the freedom to
increase the amount of services, broaden the scope of services rendered,
TABLE 1 Essentials of New Organizational Models in Community Oriented
Primary Care
Nonprofit corporation
Broad focus: Patient and community oriented
primary illness/wellness continuum
Not dependent on a particular physician
Team approach
Humanistic, with sound management
Noninstitutional base
Decentralized system
Medical and nonmedical linkages
Flexibility for experimentation
Strong professional leadership and administration
Reinvest health dollars in primary care
Pluralistic funding
Source: Andrus, L.H., and Voelm, G. An Approach to the Organization of Primary Care.
Article in Primary Care at the Crossroads. Special issue of Family and Community Health,
The Journal of Health Promotion and Maintenance, Vol. 3, No. 2, August 1980.
OCR for page 236
236
PART II: PRACTICAL APPLICATIONS
TABLE 2 Elements of Family Physician-Family Nurse Practitioner
Co-Practice Model
Common group of patients
Intentionally share clinical care for patients
Consult with each other
Shared decision making about practice's clinical activities
Shared decision making about practice's administrative activities
See themselves as colleagues
See themselves and the practice as interdependent unit
Mutual accountability
Source: O'Hara Devereaux, M., Andrus, L.H., Quilter-Dervin, P., and Dervin, J.V. Co-
Practice: Family Narse Practitioner-Family Physician: Comprehensive Health Services Modelfor
the Fatare. (In press)
and develop home care and community health programs. The professional
advantages to the physician in team practice include: having someone with
whom to share difficult patients; increased physician time for more serious
patient problems; and more time for acute hospital, emergency, and ob-
stetrical care. The addition of a family nurse practitioner to a practice is
critical to the expanded practice style necessary for true COPC (see Table
31.
The study of practice activities indicates that family practice teams with
family nurse practitioners, as compared to funnily physicians practicing with-
out faintly nurse practitioners, have incorporated many more expanded
activities. This was true for rural, urban, private, and public settings. These
findings suggest the ability of the family practice team to exhibit more
promise for delivery of COPC in a variety of communities. Although study
TABLE 3 Comparison of Family Physicians Working With Family Nurse
Practitioners Versus Family Physicians Working Without a Family Nurse
Practitioner
P ract icel C o m m ~ n ity A ctivities
Increased preventive health services
Increased home visits
Increased elder care activities
Increased prenatal classes
Increased group education classes
Increased community health programs
Increased CPR training
Source: O'Hara Devereaux, M., Andrus, L.H., Quilter-Dervin, P., and Dervin, J.V. Co-
Practice: Family Nurse Practitioner-Family Physician: Comprehensive Health Services Modelfor
the Fatare. (In press)
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Partnership for Health
237
of team practice is in its early developmental stages, results such as these
are positive and more intensive study of these types of practices is warranted.
Implementing the Foundation for Comprehensive Health Services' model
of COPC and the institution of the family practice team as the nucleus of
providers was not without problems. Table 4 lists some of the system
problems a public, nonprofit organization such as this has faced.
Other major problems exist in the development of the foundation's sys-
tem, particularly those that result from the education of health care profes-
sionals. This is because there has been a divorce between service and
education that results in little articulation between the two. Curriculum
overemphasizes disease in training health professionals, and the ability to
conceptualize and apply COPC care is lacking in almost all categories of
primary care providers. There is a lack of interdisciplinary education in
primary care that continues to promote the physician-only model and the
physician-entrepreneurial model. Physicians continue to have inappropriate
socialization for COPC and team practice and develop a competitive and
isolated style of delivering care. Additionally, the role of the epidemiologist
and public health professional is not understood by the traditional service
providers, such as doctors and nurses. The Foundation for Comprehensive
Health Services has found it necessary to provide intensive and ongoing
orientation and training in family practice team operations and COPC to
move toward its goal of comprehensive care. Education programs in the
future need to decentralize into communities to develop clinicians and
administrators who have a knowledge base that will be applicable to the
needs of COPC. For professionals to learn to work together, interdiscipli-
nary curricula are needed in the major professions to replace the single
discipline approach to care of patients. Epidemiology and community health
need to be integrated into clinical curricula so that primary care providers
learn to relate to health in the larger context.
TABLE 4 Problems of New Models of Community Oriented Primary Care
Difficulties in financial viability of clinics in underserved areas
Low reimbursement for primary care and nonillness care
Public view community clinic = Free clinic/welfare clinic
Nonprofit = Okay to show a loss (expected)
Variable physician satisfaction and productivity
Difficult physician recruitment and retention
Local medical communities often not supportive
Physician resistance to systematization
Nonprofit status results in high public scrutiny
(high administrative costs)
Orchestrating multiple funding
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238
PART II: PRACTICAL APPLICATIO NS
The current educational realities have resulted in isolated community
clinics and primary care practices, since these are the models that providers
learn about in training. These models are not viable in this day and age.
Primary care organizations and providers are not equipped personally or
organizationally to compete with existing institutional bases moving toward
noncommunity-oriented primary care programs. If COPC is truly to survive,
we need noninstitutional-based systems that offer the consumer a different
model of care and that can successfully compete with the dominating in-
stitutional-based service model. There is no evidence that isolated com-
munity clinics and practices are going to be able to effectively meet and
develop alternative models to the continuing trend toward institutionali-
zation. There is little evidence that institutional-based systems offer true
COPC, but rather they develop primary care—or a likeness—as one aspect
of their secondary and tertiary programs within the medical model.
A public, nonprofit, noninstitutional-based delivery system can bring
COPC to varied communities, offering a broader scope of service than the
traditional isolated practices. A system such as the Foundation for Com-
prehensive Health Services' system can succeed through rational central
management, economy of scale, and fiscally viable services, while retaining
the ability to individualize services and programs in each area.
The importance of the family practice team to the success of the model,
both in terms of economic viability and scope of services, makes it an
essential ingredient. The development of a collaborative style of practice
between a family physician and a family nurse practitioner is essential if
both these variables are tO be positive. The system and the team, with a
community rather than an institutional base, promise to be a winning com-
bination and the basis of a strong COPC system for the United States.
Representative terms from entire chapter:
family practice
