Collaborative Statement Quenches Fire Over NP Participation in PCMH, Ensures All Participants Meet Same Standards

Joint Statement on Nurse Practitioners in Patient-Centered Medical Home Demonstration Projects
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Physicians (ACP)
American Osteopathic Association (AOA)

April 15, 2009

The principles of the Patient Centered Medical Home (PCMH) were designed by the AAFP, AAP, ACP, and the AOA with comprehensive and coordinated primary care as core elements of its design. This model is congruent with the extensive, multinational evidence supporting primary care as the basis for improving the quality and cost efficiency of care.

The AAFP, AAP, ACP and AOA recognize that physicians and nurse practitioners (NPs) have common goals of providing high-quality, patient-centered, team-based care and improving the health status of those they serve. However, there are substantial differences in the nature and extent of education and training of physicians as compared with that of NPs. Further, states vary in the scope of practice that is granted to non-physician providers and in some states NPs have been granted independent practice authority by legislation. Therefore, our organizations offer the following position statements regarding the potential inclusion of nurse practitioner practices in patient-centered medical home demonstration projects:

1) Physicians and NPs complete their education and training with different types and levels of knowledge, skills, and abilities that are not equivalent but may be complementary. As trained health care professionals, physicians and NPs share a commitment to ensuring coordinated, comprehensive care for our patients that is driven by improved patient outcomes.

A. Patients with complex problems, multiple diagnoses, undiagnosed conditions, or difficult management challenges are best served by physicians working with a team of health care professionals that may include NPs, physician assistants, and other clinical team members (e.g., nurses, pharmacists, medical assistants, educators).
B. Patients must be informed of the credentials of the person providing their care to allow them to understand the background, orientation, and qualifications of the health care professionals providing their care and to better enable them to distinguish among different health care professionals.
C. Research funding is needed for the evaluation of PCMH practice organization and team based care including effective consultation between primary care physicians, subspecialists, NPs and other members of the care team as clinically indicated. Page 2 of 2

2) In the PCMH model, care for patients is best served by a multidisciplinary team where the clinical team is led by a physician. If it is necessary to test different models of the PCMH, our organizations agree that PCMH demonstration projects that include evaluation of physician-led PCMHs may also test and evaluate the effectiveness of nurse practitioner practices seeking designation as a PCMH consistent with the following:

A. In PCMH demonstration projects, all practices must meet the same eligibility requirements and recognition standards.
B. All practices involved in PCMH demonstrations must be subject to the same standards of evaluation and assessment, especially those related to quality improvement, outcomes, cost effectiveness, and patient experience.
C. All clinicians within the PCMH must operate within current state practice acts.
D. Evaluation metrics for all PCMH practices must take into account differences in the complexity of the patients seen by the practice, the business model under which the practice operates (e.g., independent private practice, practice affiliated and supported by an academic health center or grant funding, satellite practice of integrated delivery system), and the compensation model in effect for clinicians (e.g., salaried, volume-based fee-for-service, capitation, mixed).

3) Workforce policies must ensure adequate supplies of primary care physicians, nurse practitioners, and physician assistants to improve access to quality care and to avert anticipated shortages of primary care clinicians. Workforce policies and payment systems must recognize that training more nurse practitioners and physician assistants does not eliminate the need nor substitute for increasing the numbers of physicians trained to provide primary care.