Nurse-Managed Health Centers

Nurse-Managed Health Centers

Tine Hansen-Turton and Ann Ritter

“The innovation point is the pivotal moment when talented and motivated people seek the opportunity to act on their ideas and dreams.”

—W. Arthur Porter

Nurse-managed health centers (NMHCs) have been established by innovative health care providers who are eager to extend the reach of community health services. These health centers represent a promising delivery model for high-quality primary and preventive care, especially for low-income and vulnerable populations. In addition, they serve an important role in nursing education, acting as clinical education sites for nurses and other health professionals throughout the United States. By supporting increased funding and enhanced reimbursement for this model of care, policymakers can encourage the sustainability of existing nurse-managed primary care access points and improve clinical education opportunities for the next generation of nurses.

Since its creation in 1996, the National Nursing Centers Consortium (NNCC) has worked with its health center members to pursue national- and state-level policy reform efforts that will increase the capacity of NMHCs to educate students and serve patients. (See Box 32-1 for more on the NNCC.) This chapter provides an overview of the NMHC model, the policy barriers that threaten NMHCs, and examples of recent state and federal policy initiatives designed to encourage their growth and development.

BOX 32-1

National Nursing Centers Consortium (NNCC)

The NNCC works to advance nurse-led health care through policy, consultation, programs and applied research to reduce health disparities and meet people’s primary care and wellness needs. The NNCC has published two toolkits designed to help nurses start and sustain primary care and wellness health centers. The first, entitled Community and Nurse-Managed Health Centers: Getting Them Started and Keeping Them Going, was published in 2005 and was selected as the American Journal of Nursing’s Best Book of the Year. The second, entitled Nurse-Managed Wellness Centers: Developing and Maintaining Your Center, was published in 2009. Both are available from Springer Publications. For more information about the NNCC, its members, and its current policy initiatives, visit


The Nurse-Managed Health Center Model

NMHCs are community-based health centers led by advanced practices registered nurses. Although predominantly staffed by nurse practitioners (NPs), these health centers employ a team-based approach to care that often includes social workers, health educators, registered nurses, outreach workers, collaborating physicians, and other health professionals. While the roots of the model are in public health nursing, most modern NMHCs were created beginning in the 1980s, as NPs saw their professional authority to provide care evolve, and new governmental funding sources allowed for the creation of NMHCs (King, 2008). Today, the founders of several NMHCs have been designated as “Edge Runners” by the American Academy of Nursing because their centers represent innovative models of care for which there are excellent clinical and financial outcome data (Box 32-2).

BOX 32-2

American Academy of Nursing (AAN) Edge Runners

A number of NNCC members have been recognized for their innovative work through the AAN Edge Runners project. To learn more about these outstanding health centers (and the nurses who direct them), visit the following sites:

Despite some ongoing confusion among the public, NMHCs are not nursing homes. In fact, relatively few NMHCs provide care exclusively to senior populations, and less than 10% of NMHCs’ payer mix can be attributed to Medicare (Hansen-Turton, Line, O’Connell, Rothman, & Lauby, 2004). NMHCs serve a diverse patient population, both in terms of racial and ethnic make-up, as well as age. A number of NMHCs serve exclusively pediatric patients, while most provide care to adult patients of all ages. Overall, there are approximately 250 NMHCs located throughout the country in 40 states (National Nursing Centers Consortium [NNCC], 2008). According to NNCC member data from 2010, the Northeast, the Southeast, and the Midwest are the regions of the country with the greatest numbers of NMHCs.

NNCC members vary in services but fall into two broad categories. Nurse-managed primary care centers offer a broad scope of primary care services and can serve as designated primary care providers for patients. The services provided by these clinics are comparable to those provided by federally-qualified health centers (FQHCs), and some nurse-managed primary care centers are part of the FQHC program. (See Box 32-3 for more on FQHCs.) Nurse-managed wellness centers serve as crucial entry points into the primary care system for many patients. Nurses provide health screenings, vaccinations, direct care for minor acute problems, health education, and counseling services. They also provide community-based health promotion programs to address problems such as smoking, obesity, and poor nutrition, all with the goal of improving patients’ quality of life.

BOX 32-3

Federally Qualified Health Centers (FQHCs)

Throughout the United States, federally qualified health centers (FQHCs) provide health care to medically underserved communities and vulnerable patients. Often referred to as community health centers, these community-based providers offer primary care and other health services to patients regardless of their ability to pay. The FQHC designation was created by the federal government more than 40 years ago, and health centers that are part of the FQHC program are able to access enhanced reimbursement and federal grant funding streams that are not available to other safety net providers. The FQHC program has specific requirements for participation and is administered by the U.S. Health Resources and Services Administration (HRSA) Bureau of Primary Health Care, which is part of the U.S. Department of Health and Human Services. There are currently 1200 FQHCs in the U.S., serving more than 20 million people each year.

For more information about the funding requirements of the Federally Qualified Health Center Program, visit the website of the HRSA Bureau of Primary Health Care at For more information on Federally Qualified Health Centers generally, visit the website of the National Association of Community Health Centers at


NMHCs also provide support, outreach, and counseling services that are integrated into the larger community. This approach takes into account not only diagnosis of disease and medication therapies, but also innovative approaches to lifestyle, community, and environmental issues that can significantly impact patients’ health. One such example of this kind of service integration can be found at Eleventh Street Family Health Services of Drexel University, an NMHC serving public housing residents in Philadelphia. This nationally-recognized health center provides an array of services to the community, including comprehensive primary care and integrated behavioral health services. A team of social workers, educators, nurses, outreach workers, and others conduct health screenings, group exercise and cooking classes, and outreach programs to prevent lead poisoning and reduce asthma complications in children (Ferrari & Rideout, 2005). In addition, the health center has recently developed an outdoor garden on-site to increase access to nutritious food and further address the social determinants of health in its community (Drexel University, 2009).

Quality of Care in Nurse-Managed Health Centers

Comprehensive, team-based care and enabling services in NMHCs result in excellent outcomes for patients. Studies have shown that NPs provide high-quality primary care with outcomes similar to those of physicians (Mundinger et al., 2000; Lenz, Mundinger, Kane, Hopkins, & Lin, 2004). An evaluation of 11 NMHCs in Pennsylvania (funded by the Centers for Medicare and Medicaid Services) found that NMHCs also had higher patient retention rates and lower patient hospitalization rates when compared with similar safety-net providers (i.e., physician-managed community health centers) (Hansen-Turton et al., 2004, p. 5). NMHCs consistently receive high patient satisfaction ratings, with patients giving especially high marks in areas such as “being treated with respect” and “explaining things to you” (Benkert, George, Tanner, Barkauskas, Pohl, & Marszalek, 2007, p. 107).

The Role of Nurse-Managed Health Centers in Health Workforce Development

In addition to providing services directly to clients, NMHCs also play an important role in health professions education. More than 85 nursing schools operate NMHCs that provide care to patients and enhance learning and practice opportunities for students and faculty (NNCC, 2009a). A member survey conducted by NNCC in 2009 found that the largest percentage of health professions students completing clinical rotations in NMHCs were bachelors-level nursing students (49% of all students), followed by masters-level NP students (22%) (NNCC, 2009b). These centers also provided clinical opportunities to students in associates degree and doctoral nursing programs. Also, hundreds of students in medicine, social work, pharmacy, and dentistry programs complete clinical rotations annually in NMHCs (Institute for Nursing Centers, 2008).

Challenges to Sustainability

Availability of Federal Funding

NMHCs are safety net providers for patients regardless of their ability to pay. About 35% to 40% of NMHC patients are uninsured (Institute for Nursing Centers, 2008). NMHCs use a sliding fee scale to collect payment from uninsured patients, but these contributions alone do not cover the actual cost of care. As a result, they rely heavily on charitable grants in order to make up the difference, which translates into greater year-to-year budget instability for many health centers. Lack of access to predictable governmental funding and inconsistent reimbursement from insurers compounds the problem, leaving hundreds of thousands of low-income and vulnerable patients throughout the country at risk of losing their primary source of health care.

Many NMHCs in the U.S. were initially launched with start-up grants from the Health Resources and Services Administration (HRSA) Bureau of Health Professions’ Division of Nursing. Recognizing the important role that NMHCs could play in providing clinical education placements for nursing students and faculty, the Division of Nursing funded NMHCs through its “special projects” program (King, 2008, p. 14). However, these grants were nonrenewable and many schools found themselves unable to identify and secure sustainable long-term funding once the grant period had ended. As a result, many NMHCs closed their doors after Division of Nursing funding dried up. Meanwhile, the remaining health centers focused on acquiring funding from private foundations and improving reimbursement from third-party payers, all with varying degrees of success.

A small minority of the surviving academic NMHCs have been able to achieve fiscal sustainability by becoming part of the FQHC program, administered by the HRSA Bureau of Primary Health Care (a separate administrative entity from the HRSA Bureau of Health Professions). However, this was not an option for many academic NMHCs. The fact that many NMHCs are affiliated with schools of nursing often prevents them from qualifying for FQHC program funding because they cannot meet the program’s governance requirements.1 Inability to qualify for the FQHC program threatens the sustainability of NMHCs, because it prevents them from accessing the many benefits that the government makes available to FQHCs. For example, FQHCs are able to receive enhanced reimbursement for services provided to Medicaid beneficiaries. FQHCs were also able to qualify for special funding opportunities through the American Recovery and Reinvestment Act of 2009 (e.g., for capital improvement projects or increased staffing) that were unavailable to non-FQHCs. Without access to ongoing federal support (like that provided to FQHCs by the Bureau of Primary Health Care), NMHCs struggle to provide care to uninsured patients while remaining financially solvent.

Insurer Policies Regarding Nurse Practitioners

Lack of access to federal funding is not the only barrier to NMHC sustainability. Although many patients seen by NMHCs are uninsured, a significant proportion has publicly-funded or commercial insurance that could provide reimbursement for services. Unfortunately, many insurers do not recognize NPs as primary care providers and will not reimburse them directly. A 2008 study of managed care policies conducted by NNCC found that only 53% of insurers credential NPs as primary care providers (Hansen-Turton, Ritter, & Torgan, 2008). While some of these restrictive insurer policies appear to be attributable to a lack of understanding about NPs’ ability to provide high-quality primary care to patients, the problem is compounded by confusing state regulations regarding the legal authority of NPs to work in NMHCs with off-site physician involvement (Hansen-Turton, et al., 2008). Even though NPs are able to serve as primary care providers in all 50 states, insurers are considerably less likely to recognize NPs as primary care providers when state laws contain language requiring physician “supervision” or “delegation” for NP practice (Hansen-Turton et al., 2008). As a result, many NMHCs are not reimbursed by insurers for the care that they provide to patients, and they are less able to attract insured patients who could offset the cost of providing care to the uninsured. Recognizing that insurer policies like these result in fewer primary care access points for patients, lawmakers in Massachusetts recently passed new legislation requiring insurers to contract with NPs as primary care providers, which could serve as a model for other states (Craven & Ober, 2009).

Expanding the Reach of Nurse-Managed Health Centers

State-Level Approaches to Support Nurse-Managed Health Centers

There are a variety of state laws and policies that can impact NMHCs and their ability to serve patients (Ritter & Hansen-Turton, 2008). Because they are managed and staffed by advanced practice nurses, scope of practice, licensing, and physician collaboration laws can all have a big impact on care provided in NMHCs. Meanwhile, state laws regarding managed care insurers can either encourage or discourage patients from selecting a NMHC as his or her primary care home. In addition, some state governments with an interest in improving health care have made additional funding and other resources available to primary care practices through “medical home” demonstration projects and other quality improvement initiatives. These initiatives may or may not include nurse-led models.

One example of a recent effort that provided additional support and recognition for NMHCs is Pennsylvania Governor Edward G. Rendell’s Prescription for Pennsylvania health reform plan (Hansen-Turton, Ritter, & Valdez, 2009). Launched in 2006, this multifaceted policy initiative was designed to increase access, reduce costs, and improve health care quality by implementing an array of strategies touching a broad cross-section of the health care industry (including insurers, hospitals, providers, and others) (Commonwealth of Pennsylvania, 2009). Some of the first components of Prescription for Pennsylvania to be implemented successfully were three bills designed to improve the practice environment for NPs, certified nurse midwives, and clinical nurse specialists. These laws removed long-standing barriers to efficient advanced nursing practice by granting NPs the authority to order home health and hospice care, granting certified nurse midwives prescriptive authority, and, for the first time, defining the specific education and training requirements needed to practice as a clinical nurse specialist (Hansen-Turton et al., 2009, p. 9). In subsequent years, the Governor’s Office of Health Care Reform also spearheaded efforts to implement a medical home pilot project in southeastern Pennsylvania that is inclusive of nurse-led practices, and also inserted language into its Medicaid managed care Request for Proposals (RFP) encouraging insurers to better utilize NPs and other non-physicians in their provider networks (Pennsylvania Department of Public Welfare, 2008). Although they have not removed all barriers to independent advanced nursing practice, this combination of cost-effective policy efforts, driven by both the executive and legislative branches and championed by Governor Rendell throughout his tenure, has made it easier for NMHCs in Pennsylvania to continue providing care to low-income and vulnerable patients.

Federal-Level Approaches to Support Nurse-Managed Health Centers

Providing access to predictable, adequate public funding is the best way to support non-profit health centers that provide care to high percentages of uninsured patients. As explained above, lack of access to stable funding is one of the most challenging aspects of maintaining an NMHC. As a result, NNCC has conducted a variety of policy advocacy and education efforts with the goal of creating a dedicated funding stream for NMHCs within HRSA.

NMHC advocates have worked with Congressional health staffers to introduce the Nurse-Managed Health Clinic Investment Act in 2007 and 2009. While these bills would not provide NMHCs immediate access to the enhanced reimbursement available to FQHCs, they would define NMHCs as a recognized entity in federal statute, provide access to a new dedicated federal funding stream, and set the stage for improved reimbursement in the future.

The Nurse-Managed Health Clinic Investment Act (S. 2112) was first introduced in the Senate by Senators Daniel Inouye (D-HI) and Lamar Alexander (R-TN) in 2007. This piece of legislation would have created a $50 million grant program to support NMHCs, to be administered by HRSA’s Bureau of Primary Health Care. Ultimately, this bill died in committee, but it helped lay the groundwork for reintroduction of the bill.

The Nurse-Managed Health Clinic Investment Act was reintroduced in early 2009 in the Senate by Senators Alexander and Inouye (S. 1104) and in the House of Representatives by Congresswoman Lois Capps (D-CA) and Congressman Lee Terry (R-NE) (H.R. 2754). Recognizing the opportunity that the Obama administration’s health reform efforts presented, Congressional staff in both chambers worked with NNCC advocates to insert language from this bill into the Patient Protection and Affordable Care Act of 2010. The new law authorizes $50 million for 2010 and additional funding as needed through fiscal year 2014, but this funding is not mandated and must be appropriated every year by Congress. Given concerns about the federal deficit, securing this appropriation will be challenging. However, NMHCs also have the opportunity to apply for funding opportunities for expanding community-based health centers for which funding is mandated and is not subject to the annual appropriations process. As the nation recognizes that it must expand its capacity for community-based primary care and wellness services, NMHCs offer an infrastructure that could be expanded to meet this need if the financial and development support is available.


Because of their unique dual role as training sites for health professionals and health care homes for vulnerable patients, NMHCs are an especially critical component of our health care system. NMHCs must be better supported to ensure that we have enough qualified providers to guarantee access to health care for all Americans and enough safety net providers to take care of vulnerable people with complex needs. Policymakers at all levels of government are beginning to understand the untapped potential of advanced practice nurses and NMHCs to improve care for patients throughout the country.

For a list of related websites, please refer to your Evolve Resources at

Mar 18, 2017 | Posted by in NURSING | Comments Off on Nurse-Managed Health Centers

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