Switch On Your HIV Smarts.

Nurse-led team paves the way at a sexual health clinic in San Francisco

, by Emily Land

Across the country, a gap between the number of people needing primary medical care and the number of primary care physicians in and entering the workforce continues to widen. To fill this gap, nurses can—and are—taking on a bigger role in health care organizations. Nurse-led medical teams, like the one employed the by sexual health clinic Magnet, a program of San Francisco AIDS Foundation, are one innovative solution employed by clinics and other healthcare organizations.

Pierre-Cedric Crouch

Pierre-Cédric Crouch, PhD, ANP-BC

“When you have a huge unmet need, and you don’t have physicians to do it all, you should leverage your nursing staff to meet those needs,” said Cedric-Pierre Crouch, PhD, ANP-BC, the nursing director of Magnet.

The number of registered nurses entering the workforce is anticipated to grow by 33% between 2012 and 2025. At the same time, the number of people needing better access to primary care services is expected to increase. “Clearly, more and more patients will see an NP [nurse practitioner] or a PA [physician assistant] as their primary care practitioner [in the coming years],” wrote Thomas Bodenheimer, MD and Laurie Bauer, RN, MSPH in a New England Journal of Medicine article.

Increasing the role of nurses in health care sounds like a simple solution, but Crouch explained that registered nurses and nurse practitioners are oftentimes limited by the state when it comes to making independent clinical decisions, which prevents them from using their medical training to independently care for patients.

“Nurses are trained to identify, essentially what is ‘normal’ and what is ‘not normal.’ With that skill set, you can provide guidance and protocols that allow nurses to use their license to diagnose and take care of clients. Nurses know about medications, how to manage side effects and how to incorporate treatments and care into everyday life. But when you get into most hospitals or clinical settings, nurses just end up following orders,” said Crouch.

In California, nurse practitioners are permitted to lead health care at clinics or other health organizations as long as they operate in consultation with a physician who is accessible by phone. (Only four nurse practitioners are allowed to work under one physician.)

Nurse-led clinics are one way that health care organizations have increased the number people they are able to serve. The idea isn’t to replace physicians, said Crouch, but rather, to supplement their efforts.

“There are many illnesses or conditions that are relatively focused and lend themselves well to protocol-based care. It makes more sense to have physicians focus on the complex care and cases that come in,” said Crouch.

Services like testing and treating sexually transmitted infections (STIs), prescribing birth control, prescribing PrEP and managing diabetes are a few examples of the kinds of protocol-based care that nurses are well-suited to handle independently. Studies on nurse-based care have found that the quality of the care delivered by nurses is similar to that of the care delivered by physicians, and patient satisfaction ratings are similar as well.

Another bonus for health care organizations that implement nurse-based models is that care can be delivered more cost-effectively than physician-delivered care. Recognizing the advantages of this model, health care organizations have increasingly relied on registered nurses (RNs) and nurse practitioners (NPs) to lead care teams, according to a 2017 Guttmacher Institute report.

“Nurses are now serving as full and essential partners on interdisciplinary health care teams,” said the Robert Wood Johnson Foundation in a briefing on nurse-led care. “APRNs [advance practice registered nurses] are opening nurse-led primary care clinics and operating independently—without physician supervision—in a growing number of states and in new settings.”

Magnet is one example of a clinic that has used the nurse-based model to effectively deliver care to a large volume of clients. The clinic employs four nurse practitioners and four registered nurses (and a few per diem nurses) to provide free sexual health services to gay, bisexual and trans men in San Francisco.

Michael Blake RN

Michael Blake, RN

“This model of care works well for us,” said Michael Blake, RN, the clinical nurse manager at Magnet. “At our clinic, the nurses do everything—from blood draws, to physical exams. We run the show. We work under protocols and procedures that are written up by the nursing director and medical director, and we follow those protocols to a T.”

The clinic provides more than 16,000 HIV and STI clinical visits every year. The most recent STI epidemiology report from San Francisco indicates that the clinic is diagnosing and treating more chlamydia and gonorrhea cases than any other clinic in the city.

The Magnet clinic also has a rapidly-growing nurse-led PrEP program. Launched in November 2014, the PrEP Health Program has enrolled more than 2,000 people at risk for HIV.

Last summer, Pierre-Cedric Crouch, PhD, ANP-BC, ACRN, the director of nursing at Strut shared information about a nurse-led PrEP clinic model of care at AIDS 2016. Read more about how the program has increased access to free PrEP services in San Francisco.

“Expanding roles of nurses can help fill gaps in the health care system,” said Crouch. “We need to advocate for health care providers to function to the full extent of their licensure.” 

Read more about the growing role of nurses in health care, in this article by Thomas Bodenheimer, MD and Laurie Bauer, RN, MSPH published in the New England Journal of Medicine.


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