Policy and Advocacy for Improving Population Health

NURS 6050C: Policy and Advocacy for Improving Population Health


            Measuring the quality of healthcare in the United States is difficult because of the decentralization of the delivery system. Moreover, there are numerous quality indicators which vary from one organization to the next. The Institute of Medicine (2001) suggests focusing on six quality metrics: safety, effectiveness, patient-centered care, timeliness, efficiency, and equitable delivery of care (The Institute of Medicine [IOM], 2001). To improve these areas of concern, we must measure outcomes, identify strengths and weaknesses, and then work collaboratively to implement changes throughout the system uniformly. Significant strides must be made to improve the quality of care in the United States.

Healthcare Disparity in Rural America

            According to the National Organization of State Offices of Rural Health (2018), about 62 million people or 20% of the population reside in rural areas. These citizens are more likely to live in poverty (15.4%) than Urban Americans (11.9%), and they lack access to critical care centers; the majority of the population (76%) must drive over an hour to access a level one or two trauma center. Despite the economic disparity, rural Americans pay approximately 7% more out of pocket for healthcare services than their metropolitan counterparts (National Organization of State Offices of Rural Health, 2018). However, the lack of available primary care providers is arguably the most problematic barrier to quality care in rural America. “There are 4,118 primary care Health Professional Shortage Areas (HPSAs) in rural and frontier areas of all U.S. states and territories compared to 1,960 in metropolitan areas” (National Organization of State Offices of Rural Health, 2018, para 1). Rural communities have about half the number of specialists, with the most significant discrepancy occurring in mental health services. Only 10% of all psychiatrists in the country practice in rural settings (National Organization of State Offices of Rural Health, 2018).

            Agarwal and Slabach (2018) contend that rural citizens are sicker, and suffer from more chronic health conditions more than urban Americans. Access to care remains a primary barrier for rural residents. Geographic isolation is a relatively non-modifiable factor; however, provider availability can and should be addressed. Providers that do serve rural areas often lack adequate staff and other critical resources (Agarwal & Slabach, 2018). Moreover, the patient population presents with a variety of challenges. The Rural Health Information Hub (2017) asserts that rural populations engage in poor health behaviors including substance abuse, smoking, poor diet, lack of exercise, poor weight control, and lack of adequate sleep. Collectively, the life expectancy of all ethnicities is lower in rural areas than in metropolitan areas (Agarwal & Slabach, 2017). 

Improving Healthcare in Rural America

            Nurses outnumber all other healthcare professionals, and are the key to improving healthcare access and outcomes in rural populations. Ortiz et al. (2018) report that the scope of practice (SOP) for Advanced Practice Registered Nurses (ARNPs) varies significantly from one state to the next. Full practice authority states allow ARNPs to practice at the top of their license and abilities. They can examine patients, order and interpret diagnostic tests, and prescribe medications, including controlled substances, without any restrictions and are governed solely by the board of nursing within their state. Reduced practice states limit the ability of the ARNP to engage in at least one element of clinical practice, and require the ARNP to have a collaborative agreement with a physician. Restrictive practice states not only limit the ability of ARNPs, but also require them to practice under the supervision of a physician (Ortiz et al., 2017).

Research indicates that states with SOP limitations for ARNPs have 40% fewer primary care providers. These restrictions compound barriers to care for rural populations and exacerbate health disparities. A recent meta-analysis focusing on SOP for ARNPs confirmed that expanding their SOP improved the availability of providers, increased access and utilization of healthcare services, and increased the quality of care provided (Ortiz et al., 2018). Because ARNPs are already licensed and practicing in rural areas, expanding their SOP would immediately improve healthcare to rural Americans, and help improve the overall quality of the healthcare system.

Equitable Quality Improvement

Expanding SOP for ARNPs to decrease health disparities in rural populations directly impacts equitable resource allocation, thereby improving quality. The IOM maintains that the quality of healthcare should not vary based on age, gender, income, race, or geography. However, disparities continue to persist in rural areas.  “Collaborative models of practice, in which all health professionals practice to the full extent of their education and training, optimize the efficiency and quality of care for patients and enhance the satisfaction of healthcare providers” (Ortiz et al., 2018, para 5). Unfortunately, SOP has become a turf war between physicians and ARNPs. This dynamic is counterproductive and also inhibits quality care in rural communities. Healthcare providers and policymakers must focus on health outcomes and patient-centered care, and work together to expand the SOP for ARNPs. This intervention will increase access to care for rural residents and improve the quality of healthcare in the United States.                          

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