Working in Wyoming where there are only two humans per square mile (on average), nurse practitioner Mary Behrens, MS, FNP-BC, FAANP provides vital health care capacity to mainly rural populations. In this podcast she describes the role of the nurse practitioner, a discipline that is growing rapidly. She also discussed some of the ways a nurse practitioner can help reduce health disparities – from recognizing the unique and complex needs of patients with comorbidities, to facilitating physical therapy and physical activity. With Rose Gonzalez.
The increasing role of nurse practitioners in reducing health disparities.
Featuring Mary Behrens.
[Recorded March 2019]
Rose: Hello. You are listening to the Health Disparities Podcast from Movement Is Life. Conversations about health disparities with people who are working to eliminate them. I’m Dr. Rose Gonzalez, one of the registered nurses on the Movement Is Life steering committee and joining me today is Mary Behrens, a family nurse practitioner from Wyoming here to discuss how nurse practitioners impact health disparities. Welcome, Mary. Thank you for joining me today.
Mary: Thank you, Rose.
Rose: So, Mary, why don’t you tell me a little bit about yourself. Where you’re from, kind of the area you’re from and your work, as a nurse practitioner.
Mary: Okay, so, I work as a family nurse practitioner in Wyoming, which is the smallest populated state in the union and, also, it’s a very large state. So, we have less than two people per square mile. I work in an all nurse practitioner clinic and that means we can take care of all problems. I can diagnose and treat common ailments. I can manage uncomplicated chronic illnesses such as diabetes and hypertension, as examples. Having been elected at three levels of government, I know the struggles lawmakers go through to meet the cost associated with chronic illness, Medicare, Medicaid and healthcare disparities.
Rose: So, nurse practitioners, I hear a lot about nurse practitioners, and I know you represent an organization of nurse practitioners. It seems like that term, nurse practitioners, is just becoming more prevalent today and sounds like they do a lot of the same things that physicians do. Talk to me about the organization that you represent on Movement Is Life and some of the work that they’re doing in healthcare.
Mary: Okay, so, AANP, which is the American Association of Nurse Practitioners, represents over 270,000 nurse practitioners across our country. They are primarily delivering primary care to millions of Americans who might not have access to care. It is the voice for nurse practitioners and also, they’re patients. Actually, last year, nurse practitioners saw over 1.6 billion visits and AANP advocates for nurse practitioners that they can have full practice authority, which means that they can practice to the fullest of their education.
Rose: Of their education. The fullest extent of their education and licensure, which means, like, again, I can come in as a patient. You can see what’s wrong with me, identify it, then, you can treat me, give me a prescription, and follow me, and actually, follow me as a patient. Right?
Mary: Yes, yes.
Rose: Through my lifespan in many ways. Right?
Mary: Right, right. The interesting thing, there’s about, 80% of the nurse practitioners work in primary care and 50% have actually hospital privileges.
Rose: Wow, so, now, they’re able to be in the hospital, too.
Mary: Correct. So, the majority is in primary care, but you can also be involved in acute and specialty care.
Rose: So, with nurse practitioners, do you think that the nurse practitioners, do they practice, primarily, like in a state like Wyoming or are they in…I hear that you said they’re growing and we have large numbers. So, they function in rural, as well as, urban areas?
Mary: Right. So, you’ll see nurse practitioners all over the United States, but a lot of nurse practitioners do work in rural areas, where your patients are the sickest and the poorest and the most uninsured, but they also work in urban environments. I think about a nurse practitioner during Hurricane Katrina, down in New Orleans, which is an urban area and their people were struggling and so, she started Operation House Call and she went to where the patients were the neediest, in their home. She, actually, wrote a book called, “House Calls 101”. So, that is exciting. She, right now, has a clinic in a public housing area, again, being close to the patient. So, her mantra and my mantra is you need to go to where the patient is.
Rose: Okay, so, seeing that’s one of their mantras, going to where the patient is, talk to me a little bit about how they fit into the healthcare disparities, and when I say, healthcare disparities, I really mean how people are treated differently in different areas of the country because of where they live or because of the color of their skin or because of the language that they speak. How do nurse practitioners, since you say they go to where the patient is, how are they addressing healthcare disparities?
Mary: I think the fact that they tend to work in primary care, where people, this is the first place, usually, go to receive care, and they are located in areas of either rural areas or very urban areas, so, that they have a clinic that is easily accessible. I know in my own practice, we saw anyone that walked through our door whether Medicare or Medicaid and we saw many patients, also, from the jail.
Rose: So, they see Medicare/Medicaid. Do they bill independently? So, they have their own practice, many?
Mary: Right, if you have full practice authority and, interestingly enough, there are only 23 states that have full practice authority, and then, other states are working towards it and so, yes. If you have your own private practice and hangout your shingle, so to speak, you would do your own billing. Now, if you worked under a physician practice, then that practice would do the billing for you.
Rose: So, that gives you a lot of independence, then because could see the patients, you could bill for them, you could get reimbursement. So, you can setup your clinics anywhere.
Mary: Correct. I think that’s an important thing, right. The other thing you see a lot of nurse practitioners, too, in the concept of the minute clinics. Now, so, in your Walgreens that might have a minute clinic or CVS pharmacies, I believe, have minute clinics. They’re within easy access for people to get seen.
Rose: So, let’s go back to the disparities issue with if they’re working in underserved areas, probably in rural areas that are pretty underserved, what kind of challenges do you think they run into working with the different populations? Is it hard for them to work with a patient, let’s say, who doesn’t speak their same language or how do they go about interacting with the patients because I think people don’t really have an understanding? They understand what a doctor is and we’re trying to clarify what a nurse practitioner does, do you see that maybe they, because of their approach and their different mode of training that they can communicate better with the patient and interact patient and that way help to decrease disparities?
Mary: So, a nurse practitioner is a nurse first, and then, gets additional education and training to work with the patient. So, I think our focus is a little different. We tend to look at the whole patient, not just the disease process. So, even though we might have a disease going on, we also are concerned with how is this person coping with this disease? Are they able to pay for their medications? What is the cheapest medication and are they even going to take their medications? Also, I think it’s important to that, once they understand about how important the medications are and they’re still having problems, hey, call me if you have a question or a problem. I want to know. So, when we’re also talking about language issues and, certainly, that is a challenge, I think it’s important to have someone there that can help you interpret, but those are, certainly, challenges and I have experienced that in my own practice of, perhaps, the family bringing a younger member that can speak English and that makes it very difficult when you’re talking about the patient/client relationship. So, having interpreters, and that’s very difficult in a rural area.
Rose: So that must put the nurse practitioner in an awkward position to if they don’t understand the language, the family member comes in, you hope that that family member is not a child.
Mary: I, actually, had a ten-year-old come in with a woman who had woman’s health issues. So, as you could imagine, I needed actually to check with the hospital and find someone that could speak Spanish because I knew this wasn’t going to work.
Rose: It doesn’t sound like that’s a good situation but good for you for reaching out for resources. I, also, heard some nurse practitioners dealing with almost going the extra mile for their patients because it sounds like they develop a very good relationship. For instance, a patient comes in and says, “I don’t have enough money. I don’t know if I have money for my scripts. I’ve heard stories about nurse practitioners going the extra mile and maybe researching maybe pharmacies for their patients?
Mary: Right. In fact, that’s just a common thing in our practice every day. Certainly, usually, generics are cheaper, but we call around and kind of learn where the cheapest medications are. If there’s any help at pharmacies, sometimes, if they fill-out a form and they reach a certain income, their income allows them to get some special help, but if they’re not going to take their medication, then, the prescription isn’t very important.
Rose: Right, right. You can write a script. If they can’t afford it and they can’t go to that pharmacy to pick it up, it’s useless to impact their disease process.
Mary: You really do have to be aware of costs.
Rose: So, I want to get to a little bit about the Vicious Cycle that we talk about in Movement Is Life, the coalition that you are a representative and sit on. When we talk about the Vicious Cycle of the joint pain, inactivity, obesity, comorbid conditions that occur with that, cardiac disease, do you, nurse practitioners, see a lot of patients with joint pain and then the comorbid conditions that arise due to inactivity?
Mary: Absolutely. I was going to say. One of the things, usually, a symptom isn’t isolated and, frequently, when you do see someone with joint pain, they may be overweight, and they also might be diabetic. So, it does raise concerns and, you know, the other issue that I see, if you just tell someone you need to walk more, and the person says I’m having trouble getting out of the chair, that’s probably not the best advice. Also, many times, is it safe or do they have a place to walk or how do I work walking in when I’m raising three children and I have a part-time job, and there just isn’t time in my day. So, I think, as a nurse practitioner, we have to be very creative of what we’re talking about in movement. For example, maybe I can only walk for five minutes and I need to break it up into four different stages instead of telling someone to go walk for a couple of miles a day.
Rose: Sounds practical looking at it. So, again, using your education and training of really viewing the whole patient and looking at, you know, we already talked about some of the social determinants, lack of finances to buy maybe prescription medications. Now, what if they don’t have the time or the space, the wherewithal to be able to walk, giving them recommendations. So, looking at the whole picture, that is the holistic care that comes through your training.
Mary: Right, right. The other thing, I think, is follow-up. If you give someone a plan, I think it’s really important to do follow-up to see that they’re able to do what is suggested and if that’s not working, to try to figure something else out. But I always think nurses are very creative.
Rose: I agree. I agree. So, your role on the steering committee, what do you believe you bring to the table, to the Movement Is Life steering committee?
Mary: Well, I think I bring the nurse practitioner role to the table. I think sometimes we have many physicians and other kinds of physical therapists and PA’s, it’s all really, great that we’re working as a team. I think we just can’t have one voice, but I think that nurse practitioners have a long history in how do we help prevent the disease process before it starts? What can I do in my life to reduce my disease process from going further?
Rose: When you see patients, that relationship in your practice and what you’ve seen with nurse practitioners there, is there a more comfortable relationship that you would say you believe occurs than with many other providers because of your training? Do you see the patients? Are they more open or more able to setup that partnership with you because of your holistic approach?
Mary: Yes. Stats have shown that nurse practitioners tend to spend more time with their patients. I am a family nurse practitioner, but I did do a lot of women’s health and what was interesting, many times, women would come and say, “I feel more comfortable seeing a woman.” Sometimes, just doctors scare somebody away. So, as a nurse practitioner, and this is true with nurses in hospitals, too, that sometimes patients feel more comfortable, maybe not talking to the doctor, so to speak, but I found that was a common theme with many of my patients.
Rose: Now, do nurse practitioners work with physicians? You say they have a good relationship with them?
Mary: Yes, absolutely. It’s very important we have good relationships with physicians because we need to refer to specialists and I also had to chuckle at my own practice because I had many physicians that referred patients to me because they thought I might do a better job working with this patient.
Rose: That’s interesting. That shows acceptance as partners in that healthcare arena, rather than the opposition we typically hear from providers. You say the numbers are growing. Do you think that nurse practitioners will see more, then? And, do you think they’ll be able to better address health disparities across the nation?
Mary: Okay, right now, there’s over 270,000 nurse practitioners and we’re graduating around 28,000 a year. So, it’s growing in leaps and bounds.
Rose: Now, do you think because of their approach that they would be able to address the differences in care that happen because you can access a provider. So, really, addressing health disparities?
Mary: Absolutely, I think we’re going to see nurse practitioners working in all sorts of areas, whether it’s in rural or in towns. I also think that if you can grow nurse practitioners in health disparity areas that if the nurse practitioner looks like their clients that is important, too.
Rose: Do you think there are efforts being made to kind of encourage people of color to come into nursing and then to move on to become nurse practitioners?
Mary: I think that is key and also with Latino, Asian, Native American, too, a lot of encouragement.
Rose: And African American probably, too.
Mary: Yes, absolutely.
Rose: I know that the National Black Nurses Association has a role in helping to get the messaging out. So, you think that can help to improve where the provider than looks a little bit more like the patient.
Mary: Correct. And, I think schools are beginning, I think that also is a mission of many of the schools of nursing and schools of nurse practitioners that we need to be focusing on a broader scope.
Rose: Now, does the American Association of Nurse Practitioners, you’re a member and you see them trying to play a bigger role maybe and reaching out to diverse communities and really welcoming, encouraging nurse practitioners to work and maybe rural, as well as, urban areas that, maybe, are underserved?
Mary: Right. Well, actually, the nurse practitioner movement did start in rural Colorado and I think statistics have borne out that you do see more nurse practitioners, well, in healthcare disparate areas. In other words, there are no physicians practicing. So, I think that they have done quite a bit in this area and I think it’s only going to grow.
Rose: That’s wonderful. So, let me ask you, if you were to leave our listeners with some healthcare pearls of wisdom related to healthcare encounters, you know, since you seem to epitomize, nurse practitioners seems to epitomize, in many ways, that’s how they’re trained, really, that crucial patient/provider relationship that leads to optimal health encounters and, hopefully, health. If you were to leave our listeners with some healthcare pearls of wisdom related to these health encounters what would they be?
Mary: Don’t judge a book by its cover. One of my patients came to my office. She was dressed in orange, shackles, chains. She had a guard and the guard said to me that she was a flight risk. I looked at her and she looked pretty, sad. I knew right away that I needed to provide an environment that I could see her in. So, I told the guard that I needed to have the chains off to examine her and we needed privacy. She kind of looked at me strangely and I said, “Well, this is the only way it’s going to work.” And so, the guard, actually, I provided a chair outside of my office but this particular client, then, just kind of spilled her heart and soul out. She had been arrested but her mother had had a drug party at the home, and she swore she had not been involved, yet, she got scooped up. She was 15 years old and it was just a very difficult time. I got to follow her for over two years, and I watched her grow and blossom. When she was in jail, she told me the only time she felt normal was when she came to visit me. Now, she graduated from high school. She doesn’t do drugs. She didn’t get pregnant and she has her high school diploma.
Rose: Oh, my gosh. So, we never know how we’re going to impact that one individual. What we do impacts that one individual. Certainly, you, having the courage because you may have been scared. I don’t know if you were scared when you saw her in shackles. You know, you think about the worse when you see people and like you said, you know.
Mary: Something just told me looking at her, but I think, probably my years of nursing experience, that somehow, I knew there was something more to this story.
Rose: And, you made a difference in this young woman’s life. You may have, you know, really, changed her life for the better and that was just in one healthcare encounter. Well, in the relationship that you developed over the years with her as her provider. That’s a fabulous story. Thank you for sharing that. So, I want to thank you for joining today and sharing in the stories. They’re marvelous. I wish nurse practitioners much success in their endeavors and in really reaching out to our communities that so desperately need the care that they give. So, I want to thank you for joining us today on the MIL Health Disparities Podcast. Please checkout our website at movementislifecaucus.com and join us in moving the needle towards health equity in the musculoskeletal arena.
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