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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.

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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 careor a likenessas 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.