Community-based nurses meet underserved patients where they’re at

Oregon Health & Science University and Adventist Health Tillamook are working together to bring health care services directly to underserved residents of Northwest Oregon’s Tillamook and Columbia counties — and may help other U.S. communities do the same.

The collaboration aims to make the community-based nursing services program, which Adventist Health offers through its Tillamook and Vernonia primary care clinics, financially sustainable by making the case for Medicaid and other health insurance payors to cover the care the program delivers. Adventist Health currently funds the program on its own.

The effort is supported by a $1.3 million, three-year grant from the American Nurses Foundation. It’s among 10 projects nationwide that are collectively being awarded more than $14 million through the Reimagining Nursing Initiative, which supports bold, nurse-led ideas to help nurses meet the health care needs of the future.

“Our vision of care isn’t boxed in by the walls of a medical facility,” said the project’s lead, Seiko Izumi, Ph.D., R.N., an associate professor in the OHSU School of Nursing. “Instead of replicating the current delivery model where people come to clinics to receive care, we see nurses go out into the community where people live to deliver the care they need, and their services are covered by insurance. We’re envisioning a new world — for nurses and their communities — that embodies truly person-centered, accessible care.”

Adventist Health’s community-based nursing service program began in 2017, when the health system started operating a primary care clinic in Vernonia and realized a variety of barriers prevented many local residents from coming to the clinic. Some patients lacked reliable transportation to physically get to a clinic, while others distrusted health care systems due to historical discrimination or mental health issues, such as paranoia. The same community members would sometimes see their blood pressure, diabetes and other chronic conditions worsen until they needed more advanced care at a hospital.

To help these patients keep their health in check, a nurse from the Vernonia clinic began visiting patients wherever they were at — in their homes, or on the street if they didn’t have a home. The nurse asks patients how they’re doing, checks their vital signs, draws blood samples and more. Afterward, the nurse returns to the clinic to speak with a physician who writes prescriptions, orders tests and oversees the patient’s care based on information the nurse has gathered. The program’s nurses serve as intermediaries who coordinate the patients’ preventative care.

“Some of our patients have barriers that prevent them from accessing health care at our clinics,” said Adventist Health Tillamook Physician and Clinic Services Executive Gina Seufert, B.S.N., R.N. “Community-based nursing is all about breaking down those barriers and meeting patients on their own turf.”

Today, Adventist Health also provides some community-based nursing services through nine of its primary care clinics. Adventist Health recognizes how the program helps serve local communities, and currently covers much of the program’s costs on its own. But Seufert said a more permanent financial model could help ensure the program’s longevity — and maybe even its expansion.

OHSU has two similar community-based programs called Care Transitions Innovation, or C-TraIn, and New Directions. The OHSU programs pair nurses or social workers with eligible patients who frequently come to the OHSU emergency department, or are hospitalized at OHSU with complex chronic conditions and also experience houselessness, food insecurity or other barriers to care. To help participating patients better manage their health, OHSU staff connect patients with primary care and other services. Both programs are currently supported by internal OHSU funding and reimbursement from one Portland-area Coordinated Care Organization, or CCO, although other CCOs are soon expected to reimburse the program’s care coordination as well. CCOs aim to help Medicaid-covered community members manage chronic health conditions through preventative care.

Building off OHSU’s success in obtaining reimbursement for its community-based programs, a team consisting of OHSU and Adventist Health nurse leaders and an OHSU health economist will work with health insurance payors that operate in Tillamook and Columbia counties. The project team will explore how the Adventist Health program’s services address the local payors’ needs and priorities, and develop a reimbursement proposal for the payors to consider.

If they’re successful in making the Adventist Health program’s services reimbursable, OHSU and Adventist Health hope other hospitals and health systems could use the project as a template and develop similar, financially sustainable programs throughout the U.S.

See this project’s summary on the American Nurses Foundation website: https://www.nursingworld.org/making-nursing-visible-for-healthy-communities/