North Mississippi Health Services' decision to form a clinically integrated network came with a dilemma. In its corner of Mississippi, nurse practitioners provide about 53% of patient's primary care. Most networks only include doctors, but that didn’t make sense for NMHS.
Given that the number of advanced practice clinicians is predicted to grow and the pool of physicians to shrink, North Mississippi rewrote the formula for forming successful partnerships to create a network for population health management.
Along with doctors, the network includes advanced practice clinicians.
Erik Dukes, M.D., regional medical director for North Mississippi Health Services, says it may be the model for the future. “The primary care provider mix in Mississippi today is the U.S. provider mix of tomorrow,” he told FierceHealthcare ahead of the Healthcare Financial Management Association conference in Orlando, Florida, this week, where he spoke at a session about the network the health system has created.
The Tupelo-based health system serves 24 mostly rural counties in the northeast corner of Mississippi and a few neighboring counties in Alabama. In 2016, it decided to form a clinically integrated network with the quadruple aim of providing quality, reducing costs, increasing patient satisfaction and increasing provider happiness.
A clinically integrated network brings the advantages of being part of a group, where members typically share electronic health record systems to track and help determine the best methods of clinical care delivery that are most cost effective. The networks also allow for negotiating alternative, value-based contracts with payers.
Breaking down barriers
Historically, like many hospitals, the North Mississippi health system had focused on physicians, leaving advanced practice clinicians—which in Mississippi is primarily nurse practitioners—off the radar screen, Dukes said. Yet, those nurse practitioners provide much of the area’s primary care, making one-third to one-half of specialist referrals. Mississippi ranks dead last on a list of states based on the number of active primary care physicians per 100,000 people. Physician assistants, another type of advanced practice clinician, are very underutilized in the area, with only three in the entire health system, Dukes said.
So when it formed Connected Care Partners, its clinically integrated network, the vision was to build a high-value system of care working towards that quadruple aim. That required a new strategy for providing cost-effective care in value-based contracts: a partnership that brought in those nurse practitioners.
“It sounds kind of cliché and cheesy, but it was the right thing to do,” Dukes says. “As we looked at a clinically integrated network, we had to reach out to them.” Many of the nurse practitioners work in solo or small group practices. The big challenge was how to bring them into the network.
North Mississippi Health Services had to set up its network differently than most, said David Fairchild, M.D., director of BDC Advisors, a company that worked with the health system for a year to set up the network, who also spoke at the HFMA session on Tuesday.
The changing role of ACPs
One lesson learned in Mississippi was to acknowledge the historical divide between physician practices and nurse practitioner practices. Many doctors see the nurse practitioner practices as competition.
Advanced practice clinicians have traditionally been looked at as physician “extenders” and mid-level providers. But they are taking on a new role as part of team-based care. In Mississippi, nurse practitioners in solo practice still require a supervising physician. For some people, there’s also the question of the quality of care they provide since they have less training than doctors.
The first question the health system faced when developing the network was whether the steering committee should include nurse practitioners. There was also the question of what the nurse practitioners would think about the network.
The nurse practitioners felt they were not well connected to the health system and that it favored physicians, Dukes said. They felt they had no voice and no connection to the electronic medical record system. Supervising physicians were often looked at as a “hired pen” to review and sign a subset of charts each month as required by state regulations for independent nurse practitioner practices.
A second lesson was to actively seek to understand the needs of all providers. The network development process set the stage. Instead of forming a physician steering committee, they formed a provider steering committee that was inclusive of nurse practitioners and the network included a nurse practitioner on its board. The network wanted to become the preferred partner for nurse practitioners in the region.
How to engage and recruit the nurse practitioners? It was crucial to develop credibility and establish communication. The goal was to have one high standard of primary care and to begin to measure quality. By improving quality across the network, they focused on an “all boats rise together’ philosophy. The primary care collaborative helped clarify clinical protocol needs to account for different levels of training and a newsletter was created to meet educational needs of the nurse practitioners and doctors.
The steering committee went on a tour of nurse practitioner practices to hear their ideas and issues. There were dinners and brainstorming sessions and the group developed a set of initiatives to provide value to the nurse practitioners. Those included the newsletters to highlight care guidelines, assistance with monitoring and improving quality metrics, economies of scale and preferred pricing for network-selected solutions, access to provider information including continuing education opportunities and access to a physician preceptor program with network physicians to allow providers to network and share best practices, and read-only access to the network EMR.
One nurse practitioner, who runs a group of clinics, was moved to tears that the network would reach out to them, Dukes said. But both Dukes and Fairchild said the partnership is a work in progress.
Fairchild said he thinks there will be more clinically integrated networks in the future that partner with advanced practice clinicians. “I think it’s definitely headed in that direction, reading the tea leaves,” he said.