Why nurses deserve a place in primary care


I’m feeling pretty good about myself today. My patient, recently admitted to home health care, was just not herself, low O2 sats, irregular heart rate with pain on inspiration and feeling a little clammy. While her recent surgery was a neck fusion, it still didn’t completely eliminate the possibility of a pulmonary embolism. Instead of spending 15 to 30 torturous minutes in her primary doctor’s voice mail hell, I made the call to go to the emergency room for evaluation; she was ultimately admitted. While I do not know her admitting diagnosis, I think I nailed it.

Policy wonks and health system bean counters will cringe at the thought, but it’s time to bring up another personnel conundrum: Why can’t we see the advantages to the patient, and the primary care system as a whole, of putting RNs back into primary care and specialty care offices? We’re all in cost-saving mode with primary care doctors receiving fewer reimbursement dollars. Let’s look at the long term health impact to patients instead of the short term cost.

First, what qualifies me to comment on this? I am a home health RN case manager. The majority of time, I receive your patient from the hospital because of a recent admission, usually a result of an exacerbation of a chronic disease, heart failure, COPD, uncontrolled diabetes, pneumonia. I get to see the ugly underside of a patient’s home life which directly impacts their health.

And as a result, I’m there to get them over the hump when they get home. Do they have all their medications and are they taking them correctly? Is the home set up for optimized healing? Are there stairs to get up? Is there adequate transportation to and from follow-up appointments? Is there someone there to help them bathe or better yet, do they have running water? Do they have decent food to eat?

On more than one occasion I have purchased a loaf of bread and a jar of peanut butter for a patient or most recently, a few Wendy’s hamburgers because I knew a patient didn’t have any food. I know some of you may scoff at these simple questions but I assure you, there are several home health nurses and visiting physicians nodding their heads in agreement.

Home health companies are paid by insurance companies (including Medicare) for providing a billable skill. The skill that we perform in the home where everyone benefits is teaching. We teach patients how to administer their own IV medication, we teach people about the latest, greatest medication you prescribed and their side effects, I even taught a blind man how to administer his own insulin.

Why can’t an RN spend 15 minutes with your patients at their primary care appointment to teach? Could those 15 minutes a nurse spends with a patient mean the difference between a patient being able to stay at home and manage a symptom or a long and expensive trip to the emergency room? I dare say it could. A significant portion of a PCP patient population falls under Medicare. But that doesn’t necessarily mean they are appropriate for home care as a patient is required to be home-bound. Patients still need to understand their disease process and their medication regimen.

How much of a primary doctor’s (or PA’s/NP’s) time is spent handling nonemergent issues that a nurse could handle? I suspect a good deal. Sometimes patients just need to talk to a clinician instead of making an appointment that clogs the system. While there’s a need for a medical assistant to answer phones, check vital signs and perform office tasks, they don’t know what we know. While Mrs. Jones’ four-pound weight gain in one day may not be so earth shattering in their world, in a clinician’s world it is an issue that should be dealt with quickly, not just at the end of the work day.

While we’re on the topic, let’s talk about accessibility. While my day is usually pretty benign, there are times when I need for you to address my concerns in a timely fashion. An RN in your practice can screen calls from nurses in the field and get back to me in a reasonable time, not two or three days later when I’ve already sent the patient to the hospital in fluid overload.

There is a place for RNs in the primary care and specialty care system. Their skills mesh an MD/PA/NP clinical experience with plain language teaching and knowledge base. The time an RN can spend with your patient could mean the difference between healing at home and a costly hospital stay.

The author is an anonymous nurse.

Image credit: Shutterstock.com


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