Background and Strategies
In 1993, the Independence Foundation, a private foundation established in 1932, selected nurse-managed healthcare in the greater Philadelphia region as one of its four funding priorities. This decision emerged from the Foundation’s belief that nurse-delivered care could be a viable model of healthcare for the future,as well as thefamiliarity of two of its board members withnew models of healthcare developed and implemented by nurses, in particular nurse-managed health centers. Since the centers served predominantly poor, uninsured or underinsured, and/or minority populations with limited access to healthcare, funding for these health centers was consistent with the Foundation’s newly articulated mission of supportingprograms that provided services to populations that did not ordinarily have access to them. During this almost 20-year period of funding, the Foundation (1) endowed a community health nursing chair within four Philadelphia academic nursing programs to strengthen community health nursing education; (2) sponsored programs that have served as a vehicle for promoting collaboration and cooperation among nurse-managed grantees; (3) provided initial funding and ongoing support for the Regional Nursing Centers Consortium, now the National Nursing Centers Consortium; (4) made grants to support a variety of nurse-managed health programs; and (5) conducted a midcourse review and analysis of this initiative that has been widely disseminated (King 2008).By the end of 2011, the Independence Foundation had spent close to $33 million in total on the five components of the initiative.
The history of this funding initiative illustrates how the investment strategy has changed over time in response to societal and health policy changes and to “lessons learned” from its grantees. The initial funding strategy was twofold: (1) to fund a variety of innovative nurse-managed programs that addressedan unmet healthcare need in the community, and (2) to strengthen community health nursing curricula in local schools of nursing through the endowment of chairs and direct grants. From the onset, the Independence Foundation board recognized that in order to demonstrate the viability of an emerging model of nurse-managed healthcare, it needed to commit itself to “staying the course,” by funding the initiative for many years. As the history illustrates, after the first five years of funding, the Foundation narrowed its funding focus within nurse-managed programs while simultaneously expanding the initiative to include programs and resources that supported the viability and work of nurse-managed health centers.
Historical Overview of the Nurse-managed Funding Initiative
From 1993 until 1998, the Independence Foundation entertained a range of nurse-managed healthcare proposals that fit the Foundation’s mission, were nurse-established and directed, innovative, and well-conceived. Although the Foundation anticipated that some of the programs might not survive, it believed that the “lessons learned” from those centers were very important to an understanding of what made centers viable. Among the programs funded during those first five years were an interdenominational parish nursing program; a hospital discharge follow-up program for elderly patients; nursing education curricular enhancements in cultural diversity and community nursing;a women’s health promotion center for underserved, inner-city women; nurse-managed primary care health centers; and a nurse-established center to provide support and education services to cancer patients and their families. In addition to making grants to newly established programs, planning grants were made to organizations that were in the throes of studying the feasibility of establishing a nurse-managed program to address unmet healthcare needs or in the early stages of program development.To assist in guiding the initiative’s direction and in making funding decisions, the Foundation convened an Advisory Committee, comprised of renowned nurse leaders, each member bringing a different yet complementary perspective.
By 1998, changes in federal and state reimbursement mechanisms for healthcare, the predominance of managed care organizations within the healthcare market, and welfare reform, with its far-reaching implications for financial access to healthcare for the poor, were strong influences on the Foundation’s decision to focus its funding onnurse-managed health centers that provided primary care, in addition to health promotion (i.e., wellness and disease prevention programs, family planning, and early childhood intervention assessments). It also recognized the importance of funding projects and organizations that would support the growing number of Philadelphia-area nurse-managed health centers that offered primary care. For example, changes in healthcare reimbursement regulations underscored the need to educate health policymakers, at all levels, about nurse practitioners and nurse-managed health centers, so that the centers could receive reimbursement. In 1997, 13 Philadelphia nurse-managed centers formed the Regional Nursing Centers Consortium (RNCC) to address common problems related to reimbursement, to provide national leadership in policy development to overcome obstacles to sustainability, and to educate the public about nurse-managed centers. However, after a year of operating as a volunteer organization, it became clear that the scope of work required a full-time paid director and assistant. A grant from the Independence Foundation enabled the RNCC to do this and four years later, the RNCC, having grown to 36 member centers nationwide, became the National Nursing CentersConsortium (NNCC), which in 2011 boasted over 250 members internationally.
Another important influence on the Foundation’s decision to focus the majority of its funding on nurse-managed primary care centers was their potential for long-term sustainability. Primary care, behavioral health and family services were all direct healthcare services eligible for reimbursement, albeit at times at a very limited level, whereas the health promotion services were usually not eligible for direct service reimbursement, except through grants to support specific programs, such as lead poisoning prevention, influenza immunization and smoking cessation. The first five years of funding under this initiative had demonstrated just how difficult it was to sustain nurse-managed centers that provided only health promotion services. In several instances, the Independence Foundation provided the majority of funding, and, without it, the centers could not and did not survive.
As early as 1995, the Independence Foundation recognized the importance of the centers’ data collection for documenting the scope of services provided and clients served, for tracking health outcomes, and for monitoring the quality of healthcare provided. These data were essential for grant applications and reports and critical for the NNCC’s health policy work.Between 1995 and 2000, several grants were made to develop and test data collection systems. However, by 2000/2001, the centers’ need for an electronic practice management and health record system became apparent. The practice management system would facilitate the centers’ efficient management of all aspects of their business operations. The health record system would enable them to more effectively document the care provided to patients, to track clients’ health outcomes, and to document the quality of care provided by the centers. Accordingly, the Foundation, in 2002, at least two years prior to health information technology becoming a federal priority, appropriated $500,000 for the purchase of an electronic practice management and health record system to be implemented in seven of its Philadelphia grantee centers and led the software selection and initial implementation process, with the NNCC assuming responsibility for ongoing management and data warehousing.
Independence Foundation funding was particularly crucial to the survival of the academic-based nurse-managed primary care centers in the time period from 1998 to 2003. Although they were beginning to receive reimbursement from third-party payers, the amount was minimal and did not provide for the cost-shifting necessary to accommodate the 30-90 percent of uninsured clients they served. Furthermore, federal grants obtained through HRSA’s Division of Nursing, which had supported the initial establishment and operations of centers founded by schools of nursing, had ended and, except in rare cases, were not renewable. A higher level of reimbursement was available to Federally Qualified Health Centers (FQHCs), but academic-based centers had difficulty obtaining FQHC status due to their administrative structure. While all of the academic-based Philadelphia nurse-managed health centers eventually obtained FQHC status (King 2008) through affiliations with existing FQHCs, without the Independence Foundation funding during this period, some would not have survived.
What was truly innovative about this funding model was its evolution over time and the Foundation’s identification of additional programs and resources needed to support the viability of the nurse-managed health center model of healthcare. Through its national leadership in advising healthcare policy and in positioning nurse-managed health centers as a respected, cost-effective, mainstream healthcare model, the NNCC has brought national attention to the nurse-managed model of care. Utilization of the electronic health record system enabled the centers to participate in the Pennsylvania Governor’s Chronic Care Initiative introduced in 2008 and provided the data to support their applications for formal recognition by the National Committee on Quality Assurance, resulting in at least Level 1 recognition and additional service reimbursement. As of the end of 2011, the Foundation was funding a cohort of eight, long-term granteenurse-managed health centersthat collectively in 2010 provided primary care, behavioral health, dental health and/or family planning services to over 29,000 clients during 127,327 visits. Approximately 1,500 health promotion programs with a total participation of 22,000 were conducted by these eight centers, the NNCC, and two strictly health promotion centers. With their increasing national recognition as important providers of quality healthcare, nurse-managed health centers are well-positioned to meet the anticipated increasing demand for primary healthcare and a healthcare home.
Eunice King received a diploma in nursing from the Johns Hopkins Hospital School of Nursing, a BSN from the University of Pennsylvania, a MSN in mental health nursing from Boston University, and a Ph.D. in Human Development from Bryn Mawr College. Currently, she is a Senior Program Officer and Director of Research and Evaluation for the Independence Foundation, which she joined in 2000. In addition to guiding the Foundation’s grant making under the nurse-managed health care initiative,she is the program evaluator for a National League for Nursing/ Community College of Philadelphia program, funded by the Hearst Foundations, Laerdal Medical, and the Independence Foundation, to enhance undergraduate geriatric nursing education. In conjunction with the National Nursing Centers’ Consortium, she directed the selection and successful implementation of an electronic practice management and medical record software system for use in six of the Foundation’s nurse-managed health center grantees. In 2005, she completed a retrospective, qualitative review of the Foundation’s grant making in nursing since 1988 and conducted an analysis of the challenges faced by the Philadelphia area nurse-managed health centers between 1993 and 2003 and the strategies employed to address them. Results of this work were disseminated through professional publications and presentations at national conferences.
King, E. (2008). A 10 year review of four academic nurse-managed centers: Challenges and survival strategies. Journal of Professional Nursing, 24(1):14-20.