57 percent, advanced practice clinicians (i.e., NPs, PAs, and certified nurse midwives [CNMs]) by 64 percent, and RNs by 38 percent. Yet despite that growth, according to the National Association for Community Health Centers (NACHC et al., 2008), health centers fell short by 1,843 primary care providers, including physicians, NPs, PAs, and CNMs, and by 1,384 RNs.

NACHC estimates that 56 million people lack access to a primary care medical provider (NACHC, 2007). For health centers to increase the number of patients served (for medical visits) from 16 million to 30 million, an additional 15,600 to 19,400 primary care providers are estimated to be needed. Using the current skill mix of clinicians, 36 percent of these additional providers—from 5,600 to 7,000—would be NPs/CNMs/PAs. In addition, health centers would require another 11,600–14,400 RNs. Assuming that 75 percent of the advanced practice clinicians would be NPs or CNMs, an additional 16,000–20,000 RNs would be required to meet this demand.

National statistics on the RN workforce in primary care suggest that nursing is not growing to meet this demand (Box F-1). The percent of RNs employed in ambulatory care, e.g., clinics, physicians’ offices, health centers remained virtually unchanged between 2004 and 2008, at just over 12 percent. This seemingly steady employment rate masks the gradual decline in the ambulatory care nursing workforce in a number of states. For example, the RN ambulatory care workforce in Florida grew an appreciably decelerating rate over this period: 25 percent from 2004–2006, 12 percent from 2006–2008, and virtually no change from 2008–2009. In 2007 amulatory care settings employed 7.8 percent of RNs in Pennsylvania, down from 8.4 percent 2 years earlier. In 2006 6.3 percent of RNs in California worked in ambulatory care, down from 8.3 percent only 2 years earlier (UCSF School of Nursing and CHWS, 2007). Statistics from the 2004 National Sample Survey of Registered Nurses indicate that between 17,000 and 20,000 RNs were working in health center settings. Meeting the demand for primary care services at community health centers estimated by NACHC would require a doubling of the RN workforce in health centers today, an unlikely circumstance given the prevailing trends in ambulatory care employment of RNs. Furthermore, community health centers represent only one primary care setting that will demand additional RNs. Other services and settings offering access to primary care and preventive health services and receiving enhanced support from the health reform legislation and consequently will place additional demand on RNs include workplace wellness programs, home-based primary care (e.g., Independence at Home program), nurse home visitation services, nurse-managed health centers, and community health teams.

Adoption of Health Care Support Technologies

Within the first few months in office President Obama signed economic stimulus legislation that included a significant investment to expand the HIT



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