DLT: Within the five counties in southeastern Pa., there are eight private, not-for-profit organizations that receive grants under the consolidated community health centers grant program. Seven are in Philly and one is in Delaware County. Each one provides services at multiple sites, some of which are school-based. The seven community health center grantees in Philadelphia operate 27 service delivery sites—some very large, some very small—within Philadelphia, and one in Norristown. The Delaware County grantee operates two sites, both in Chester. In addition, the Philadelphia Department of Public Health operates nine district health centers. Of these nine, one is exclusively for infectious disease screening and treatment. Finally, there are two additional private, federally qualified health centers in Philadelphia that meet the requirements to receive a community health center grant, but are not grant funded at this time.

DLT: There are two that are nurse-run. One of them is our network, which includes Abbottsford—in the middle of the Abbottsford Homes Public Housing Community in East Falls, bordering on Germantown in North Philadelphia; the Eleventh Street Family Health Services of Drexel University; and Falls Family Practice. The other is the Healthcare for the Homeless program run by the Philadelphia Health Management Corporation. There are other nurse-managed health centers in Philadelphia and across the country that have not yet become community health centers.

DLT: The parent corporation is Resources for Human Development, a private nonprofit located in Philadelphia that has human service programs in at least seven states.

DLT: For a few reasons. Nurse practitioners like any profession, would like to practice to the fullest extent of their scope of practice and their capability. Two, is the interest and desire of practicing independently. And three, nurse-managed health centers have a philosophy that is based on what nursing is all about: caring for the whole person. So, nurse managed health centers tend to have a lot of emphasis on health education programs. Our Abbottsford network is the only one in the city that has a licensed behavioral health program because we really believe that caring for people’s psychological health is as important, and in some cases more important, than their physical health.

DLT: For our center, which was funded in 1991, we had written a proposal to the federal government and proposed that this would be a nurse-managed model where a 100 percent of the primary care would be given by nurses. We were interested in testing out this model and, given the fact that only seven in the country were funded and we were one of them, the Bureau of Primary Health Care was also interested in testing the model.

DLT: Yes, but we are not totally without physicians. We have a collaborating physician. He is a medical director of another community health center in Philadelphia. He is available by phone any time we need him and he visits our health center about once every two months to review complex patients. We also have two part-time psychiatrists for our licensed behavioral health program

DLT: They must be licensed by the state as certified nurse practitioners. Usually the nurse practitioner has a Master’s degree. Between the three sites in the Abbottsford network there are eight nurse practitioners, not all full-time, and two registered nurses.

DLT: Primary care for all ages, family planning, prenatal care, mental health and drug and alcohol, health education targeted to chronic illnesses such as diabetes. We also have several youth programs: Teens Making a Difference, the Peaceful Posse for boys and the Girls Posse. We have two vans and drivers that provide transportation for patients to dentists, to our health center, to specialists, to the public assistance office if needed. We also have Americorps and community outreach teams that link patients to services, help them get onto medical insurance, prescription plans and CHIP, help them with housing, help them decipher legal materials.

DLT: We are very much looking at outcomes of nurse-managed health centers and we get utilization reports from the managed care organizations with whom we contract. We have fairly consistently seen that our patients fare better then the aggregate of all the other health centers in the network, most of which are more the traditional physician-run models, in terms of staying out of the hospital and out of the emergency room; between 10 and 15 percent improvement. We’re located almost in the patient’s backyard, so if they have a asthma attack they can wander in and it’s quicker in a lot of cases for them to get here than the emergency room. On average we see our patients about twice as often per year compared to the aggregate and we also spend more time with them. We do not see 25 patients a day. On average, the nurse practitioners see 14 visits in a full day, so they’re spending almost twice as much time with patients. They have more of an opportunity to consult with someone by phone, look something up, teach the patient. Counting our two centers—because the Eleventh Street center just opened up—we get about 7,500 patient visits a year for primary care and behavioral health. That doesn’t count the groups or the prenatal services. We have very good pregnancy outcomes in terms of having healthy normal weight babies. Specialists are used less often and prescriptions are less costly.

DLT: Not that I’m aware of, and I would think the answer is no. There are many studies comparing nurse practitioners to physicians and there was an aggregate of all the studies that was done several years ago—that study showed that the care was equal and nurse practitioners did better in the area of health education.

DLT: I don’t think so. I think there are enough patients to go around for everybody and I can tell you that, in the ten years I’ve been doing this, I’ve never had a physician tell me, "What are you doing there? We want to be serving that group of people." We’re right across the street from a hospital and still there seems to be an incredible problem with access. When we came in here, patients reported using the emergency room for their primary care and the emergency room reported to us that, after we moved in here, their census went way down. When you provide access for people they’re more likely to use a primary care provider than the emergency room and, when they’re getting ongoing primary care they’re less likely to have emergencies.

DLT: I think, for the most part, patients want someone who’s going to listen to them, provide competent care, treat them well, not keep them waiting a long time and provide a friendly and warm atmosphere where they feel comfortable. That’s what people want and I think wherever they can get it and whoever they can get it from, they’re going to go there.

DLT: Some. If they are uninsured, they do have the city health center as an option. If they do have insurance, they can go wherever they want. And 70 percent of our patients do have insurance—either Medical Assistance, a Medicare plan or a private insurer. Nowadays people come here because they’ve been referred, sort of word-of-mouth. Once they experience the care they get here, by and large they’re very pleased. We do provide a lot of extra kinds of services. Public housing is the housing of last resort. We have an inordinate number of people with mental illness. And we really do wrap our arms around the whole person and their families. Other community health centers provide a lot of extra services too, though none of them around here are licensed mental health providers and I think none of them have a van to provide transportation.

DLT: If I have a patient with unstable angina, I would probably refer them to a cardiologist. If I have a patient who I think needs surgery, whether it’s their tonsils out or hernia repair, I’ll refer them to a surgeon. When we refer to a physician it’s usually for some kind of specialty care or emergency care. And we provide 24/7 care, always on call. We have a list of physicians that we tend to refer to at the local hospital and they know us. We have a collaborating physician who is available by phone at any time.

DLT: Nurse practitioners can prescribe medications with their own prescriber number. That law came about a couple years ago—Pennsylvania was one of the last states to allow nurse practitioners to prescribe medications. You have to have a collaborating physician and you cannot prescribe outside of a certain list of medications that are outside of your scope of practice. For example, I would not prescribe cancer chemotherapy for patients. And we cannot prescribe most controlled substances, narcotics. We have a written agreement between our institution and our collaborating physician’s institution that outlines the details.