Newswise — Rush University Medical Center and the Rush University College of Nursing together are playing a major role in a successful federal pilot program that sought innovative ways to address the growing shortage of primary-care clinicians. Rush was one of five hospitals that the Centers for Medicare and Medicaid Services (CMS) tasked with developing new training methods for advanced practice registered nurses in a six-year, $200 million Graduate Nurse Education (GNE) Demonstration which will end next July.

Advanced practice nurses (APRNs) are registered nurses (RNs) with master’s degrees in nursing, or doctor of nursing practice (DNP) degrees. They are certified and licensed to assess, diagnose, and manage acute and chronic illness and provide the full range of primary care services. Hospitals and community based health care sites increasingly are relying on APRNS to deliver care as they contend with a nationwide shortage of primary care physicians.

Rush received about $12 million to fund its demonstration project. “The main focus of the demonstration project was to help our APRN graduate programs increase enrollment and thus relieve the primary care workforce shortage,” said Kathleen Delaney, PhD, PMH-NP, who directed the project at Rush. Delaney is a professor in the Rush College of Nursing’s Department of Community, Systems and Mental Health Nursing.

The Rush GNE enabled the College of Nursing to attain a 70 percent increase in nurse practitioner graduates from its baseline rate. The Rush GNE has supported about 180 semester-long APRN clinical placements — mostly nurse-practitioner students every year since the program began in 2012.

“Our graduate nursing programs are popular,” Delaney says, but clinical sites for training can be hard to find. Hospitals and community health care settings such as clinics and long-term care facilities are not reimbursed to provide graduate nursing clinical training.

When they’re willing, they do it “in kind training — for free. Reasons for providing in-kind training vary: The site may see it as part of their mission, or offer training because the advanced practice nurses they train may be more likely to work with them after graduation, Delaney says. “That’s how nurse-practitioner training works.”

Recognizing the pressure on this traditional training model, the GNE provided the funding to support and thus expand clinical training opportunities. During the pilot project, Medicare underwrote training for graduate nursing students at clinical sites in community settings, where at least half the training had to take place.

Since its inception in 1965, Medicare has financed clinical training for physicians and allied health professionals, but not for advanced-degree nurses. In 2012, anticipating the 20 million Americans who would gain health insurance under the Affordable Care Act (ACA), Medicare set out to explore whether hospitals in various scenarios across the country could develop cost-effective programs to support the graduate training of advanced practice nurses, particularly those who would eventually provide community based primary care.

It worked. A report that CMS submitted to Congress this week states that “new and diverse” clinical partners were willing to train nurse practitioner candidates if Medicare would pay them for their services. All five of the demonstration nursing schools experienced higher enrollment and graduation rates than comparison schools, according to the report.

Additionally, the full cost of training an APRN to graduation was a bargain, an estimated $30,000, compared with $150,000 for one year of community-based residency training for a primary care physician in the federally supported Teaching Health Center program.

At Rush, Delaney’s team set up training models in innovative places where students hadn't trained before, such as Free and Charitable Clinics. At those locations, the grant paid the full cost of a clinical trainer. In more traditional settings, such as a Federally Qualified Health Center, the grant might reimburse for a portion of the clinical preceptor’s (trainer’s) time.

“No one had ever systematically tried to reimburse sites for training [nurses] before,” Delaney says. “The GNE demonstrated that with nominal support, you could train students in settings” that hadn’t previously been able to take on that role. It was a really good test of feasibility.”

It would be a great thing if Medicare did underwrite graduate training for nurses, Delaney says, because “in-kind training is getting more and more difficult to sustain. Sites are very busy.”

At the same time physicians and APRNs who could train nurse practitioners are being held to ambitious productivity expectations. “And, we have many more students. The traditional in-kind training model is not going to hold up very well in the future.”

The participating hospitals will work with stakeholders to expand the principles of the GNE nationally, according to the report. “The GNE ushered in innovation in the way we train our students, and in our thinking about how we could set up different training models,” Delaney says. “No one knows the fate of the ACA, but the idea that we should keep people healthy and focus on prevention — those principles are not going to go away.”

In addition to Rush, participants in the GNE were Duke University Hospital in Durham, North Carolina.; Hospital of the University of Pennsylvania, Philadelphia; Memorial Hermann Texas Medical Center, Houston, Texas; and HonorHealth Scottsdale Osborn Medical Center, Scottsdale, Arizona. In all, the hospitals are affiliated with 19 university schools of nursing and numerous community clinical partners. 

The GNE pilot program supported the training of nurse midwives, nurse anesthetists and clinical nurse specialists, as well as nurse practitioners.