consists of the implementation of a medical home model with expanded roles for RNs. Previously, primary care providers (physicians and NPs) at the VA felt that they were not receiving enough professional support to do their jobs effectively. The new strategy calls for including staff nurses on the primary care teams. “This is not your typical staff nurse role in primary care settings,” said Catherine Rick, chief nursing officer of the VA.32 What the staff nurse brings to primary care that has not been there before is the provision of chronic care management, care coordination, health risk appraisal, health promotion, and disease prevention. Work on rolling out the VA’s medical home model began in August 2009, and the program was officially launched in April 2010. The case study in Box 3-3 illustrates how the medical home concept is being applied in the VA health system.

Community Health Centers

CHCs have a long track records of providing high-value, quality primary and preventive care in poor and underserved parts of the United States. Many also offer dental, mental health, and substance abuse and pharmacy services as well. CHCs generally are very team oriented and depend on nurses to deliver services. Nurses provide primary care, preventive services, and home visits, and many serve in administrative and leadership positions. At present, 20 million Americans receive care at CHCs in 7,500 communities (NACHC, 2009). CHC patients are less likely to have unmet medical needs, visit the emergency department for nonurgent care, or need hospitalization relative to the general population. A 2007 report by the National Association of Community Health Centers found that medical expenses for patients who receive the majority of their care at a CHC are 41 percent lower ($1,810 per person) than those for comparable patients who receive most of their care elsewhere (NACHC et al., 2007). As a result, the organization estimates that CHCs save the health care system $9.9–$17.6 billion a year (NACHC, 2009).

In 2002, the Bush Administration began a significant expansion of the CHC program, which began in the 1960s as part of the “war on poverty.” The program received another big boost in 2009 with a $2 billion investment as part of the American Recovery and Reinvestment Act. And in 2010, as part of the ACA, Congress allocated an additional $11 billion in funds to further expand the program (Whelan, 2010).

Nurse-Managed Health Centers

NMHCs have provided care for populations served by Medicare, Medicaid, and children’s health insurance programs, as well as the uninsured, since the


Personal communication, Cathy Rick, Chief Nursing Officer of the Department of Veterans Affairs, March 9, 2010.

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