Advancing Primary Care with Underserved Communities: A Case Study of the Leonard A. Lauder Community Care Nurse Practitioner Program
Surveying the landscape of primary care, the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care noted the disappointing lack of progress made on the recommendations from several previous NASEM consensus studies that paved an effective roadmap for the future of primary care (NASEM, 2021a). Their report drew from these still relevant recommendations and presented an implementation plan to achieve high-quality primary care. Starting from the premise that primary care is the turnkey for better health and health equity, the study panel focused its effort on developing an action plan grounded in community-oriented primary care that is enshrined in the Declaration of Alma-Ata, adopted at the 1978 International Conference on Primary Health Care (WHO, 2004). The panel highlighted access to primary care as the essential condition of health equity.
Building a primary care workforce ready to take on the challenge of health equity is the cornerstone of yet another NASEM (2021b) consensus study: The Future of Nursing 2020–2030. This study underscores the importance of the nurse practitioner workforce in improving access to primary care—a role established over 50 years ago for that explicit purpose. At that time, the population of the United States was rising at a much more rapid rate than the increase in physician and nursing personnel available to meet their health care needs. Unless the pattern of furnishing primary health care, particularly to underserved groups in both urban and rural areas, was drastically improved, these groups would suffer in inequitable and unnecessary ways. Visionaries at the University of Colorado, Henry Silver, MD, Professor of Pediatrics, and Loretta Ford, RN, EdD, Professor and Chair of Public Health Nursing, created a new role— the nurse practitioner—that prepared nurses to assume an expanded role in providing primary health care in areas where there are limited facilities for such care.
Upon this well-laid foundation, the NASEM reports (2021a, 2021b) sound the clarion call to increase the numbers, diversity, and distribution of primary care nurse practitioners fully equipped to incorporate the social determinants of health (SDoH) into their community-based practice to reduce health disparities and thus improve health equity. Why nurse practitioners? By 2034, there will be a shortfall between 18,000 and 48,000 primary care physicians (AAMC, 2021). Nurse practitioners, in contrast, graduate from primary care programs at three times the rate of graduating physicians entering primary care residencies. They are active in the workforce and more likely to practice in rural and underserved communities caring for low-income patients lacking adequate coverage or on Medicaid (AANP, 2022).
We present a case study of a program that leverages donor interest and passion, institutional and school commitment to health equity and social justice, nationally ranked nurse practitioner programs, and a community-engaged educational model with clinical training. Coupled with supportive experiences, the program is designed to foster skills and passion for working in underserved communities. We include a discussion of considerations for broader impact and scale of the program.
Preparing Primary Care Nurse Practitioners to Practice in Underserved Communities: A Case Study
Announced in February 2022, the Leonard A. Lauder Community Care Nurse Practitioner Program, in partnership with the University of Pennsylvania School of Nursing, exemplifies the promising effort to promote community-engaged primary care nurse practitioner education. This transformative $125 million gift—the largest gift ever to a nursing school in the United States—is an investment in primary care nurse practitioner education and the communities in which its graduates are committed to practice. The Leonard A. Lauder investment covers tuition to full-time primary care nurse practitioner students in exchange for practicing in community-based centers caring for the underserved, removing the worry of significant student debt upon graduating, and accelerating time to graduation. Deliberate efforts are made to recruit students living and practicing in under-resourced areas.
The program is guided by a framework for educating health professionals on the SDoH (NASEM, 2016). The framework situates health professions education and its related components—education (e.g., experiential and collaborative learning), organization (e.g., school/university environment, commitment to SDoH education), and community (e.g., community engagement and priorities, reciprocal commitment)—to achieve health equity. Built upon a strong university and school mission and values that align with health equity, the Leonard A. Lauder program augments nurse practitioner education at Penn through focused integration of the SDoH at the point of care and development of intersectoral leadership. Leonard A. Lauder fellows participate in experiential and collaborative learning in and with communities, where at least half of their clinical education occurs. The program is building a robust alumni network to create lifelong support to Leonard A. Lauder fellows to enhance and support community-based practice and leadership that will advance the health and well-being of communities
This collaboration with community-based centers also strengthens communities in addressing their priorities directed at better health. Program efforts include developing shared visions, relationships, and partnerships across non-health organizations to systemically address social determinants in designated communities. This reciprocal approach affords exceptional experiential learning opportunities for fellows while strengthening the infrastructure and capacity of community-based health centers to continue to address conditions that impact the health and well-being of communities.
The Leonard A. Lauder initiative brings together and enhances many of the lessons learned over the years in workforce development for underserved communities. The outcomes achieved by this program will serve as a guide to address similar health equity goals. Key elements of the program will be broadly disseminated through a biennial conference starting in 2025, in addition to publications, presentations, and sharing of resources. These efforts are designed to facilitate program replication, including simulations that facilitate addressing social determinants at the point of care and intersectoral leadership, online presentations and learnings, and processes, including student selection and mentoring, curricular innovation, and development with community partners.
Moving Beyond One Program
How will this one investment, in one program, in one school of nursing, impact the primary care needs of populations more broadly? The investment by Leonard A. Lauder is a powerful catalyst for change, one that could have a significant multiplier effect if met with public and private investment in primary care workforce development. The recommendations from the 2021 NASEM reports underscore this point, calling for federal and state resources to be deployed in sufficient quantities to be directed to the training of primary care nurse practitioners and the supporting community-based primary care workforce. Second, the program provides a path to increase the knowledge and skills in addressing SDoH. The growing evidence of improved individual and population health outcomes through collaborative care models that include and, in many cases, are driven by community stakeholders’ call for the preparation of primary care providers that can both participate and lead in such care models. Skill development is needed to enable working together across professions with other health care workers, patients, families, and communities to improve health outcomes. The lessons learned in implementing the Leonard A. Lauder program will be broadly shared to facilitate adoption and tailoring to different settings.
Enhanced funding and explicit training models for educating primary care nurse practitioners within a community-oriented framework grounded in the SDoH is an important first step. Adopting these training models could be encouraged by the health profession’s education accrediting bodies, through their revision of standards to focus on community-oriented approaches and population health outcomes (NASEM, 2021b). Revising state-level scope of practice regulations to allow nurse practitioners to function to the full extent of their education needed to address complex health and social needs, as they will be prepared to do, is also necessary (NASEM, 2021b). The Department of Veterans Affairs and roughly half of the states have adopted full practice authority for nurse practitioners, and the reluctance of the remaining half presents a barrier to quality primary care by limiting the primary care workforce for residents.
Ensuring high-quality primary care for every family involves expanding, diversifying, and aligning the primary care workforce with underserved communities (NASEM, 2021a). Directing federal funding for health professions education, such as Medicare’s Graduate Medical Education, to grow the primary care workforce would be an important first step (Aiken et al., 2018). The Leonard A. Lauder Community Care Nurse Practitioner Program will accelerate needed changes in health professionals’ primary care education and practice, particularly for underserved communities. The program provides a critically important case study for the mission of achieving equitable primary care. The commitment to building a workforce ready to meet the challenges of improving health outcomes in rural and underserved communities, and partnering with those communities in that quest, signals to the broader stakeholder community sharing these same goals—the time is now.
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Tweet this! Authors of a new #NAMPerspectives commentary examine the Leonard A. Lauder Community Care Nurse Practitioner Program as a case study for how investment in primary care workforce education can improve health equity. Read more: https://doi.org/10.31478/202302a
Tweet this! Authors of a new #NAMPerspectives argue that “the time is now” to build a workforce ready to meet the challenges of improving health outcomes in rural and underserved communities, and to partner with those communities in that quest. Read more: https://doi.org/10.31478/202302a
Tweet this! In a new #NAMPerspectives, authors outline how investments in nurse practitioner education can address health disparities by growing the primary care workforce. Read more: https://doi.org/10.31478/202302a
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References
- Aiken, L. H., J. Dahlerbruch, B. Todd, and G. Bai. 2018. The Graduate Nurse Education Demonstration—Implications for Medicare Policy. New England Journal of Medicine 378:2360-2363. https://doi.org/10.1056/NEJMp1800567.
- American Association of Medical Colleges (AAMC). 2021. AAMC Report Reinforces Mounting Physician Shortage. Available at: https://www.aamc.org/newsinsights/press-releases/aamc-report-reinforcesmounting-physician-shortage (Accessed February 9, 2022).
- American Association of Nurse Practitioners (AANC). 2022. Nurse Practitioner Fact Sheet. Available at: https://www.aanp.org/about/all-about-nps/npfact-sheet (Accessed February 9, 2022).
- National Academies of Sciences, Engineering, and Medicine (NASEM). 2016. A Framework for Educating Health Professionals to Address the Social Determinants of Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/21923.
- NASEM. 2021a. Implementing High-Quality Primary Care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983.
- NASEM. 2021b. The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/25982.
- World Health Organization. 2004. Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. 47(2):159-161.
