Retail-based care: A new way to practice

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Convenient-care clinics are opening up unprecedented opportunities for nurse practitioners and physician assistants. Here’s what you should know.

A revolution is under way in the delivery of health services, with nurse practitioners and physician assistants in the vanguard.

Walk-in clinics are quickly sprouting up within supermarkets, drugstores, and discount department stores. These facilities treat common ailments at low cost with little or no waiting. Patients have the added convenience of filling prescriptions in the host store’s pharmacy department just a few steps away.

The concept of retail-based or convenient-care clinics was launched in May 2000, when a company called QuickMedx opened a handful at Cub Foods stores in the Minneapolis-St. Paul area. By April 2007, more than a dozen companies were operating a total of 400 clinics across the country in Wal-Mart, Target, CVS, and other stores. Industry spokesmen expect expansion to explode, with a total of 1,000 clinics open by the end of the year and as many as 8,000 by 2010.

“We estimate that, if current projections hold, the number of clinics will double every year for the next three to five years,” says Tine Hansen-Turton, executive director of the Convenient Care Association, an industry organization composed of a dozen clinic companies. Providing a limited range of services, the clinics treat only ambulatory illnesses, such as flu, strep throat, ear or bladder infections, poison ivy, allergies, sunburn, and athlete’s foot. They also offer immunizations and sports physicals. Patients who present with more serious conditions are referred to a physician or emergency department.

Despite these limits, the clinics fill several service gaps in the health-care system. Open evenings and weekends with no appointments needed, they provide immediate attention when doctors’ offices are usually closed. In addition, the visits themselves often take only 10-15 minutes.

Fees range from $30 to $80, depending on the service rendered and the locality, making treatment affordable, especially for the 46.6 million Americans who are uninsured. The out-of-pocket cost is even less for insured patients who are responsible for only a co-payment.

Some clinics hire physician assistants, too

Most clinics are staffed by NPs, although some employ PAs. In fact, Hansen-Turton projects that the industry will require 10,000 NPs in the next few years.

According to the Nurse Practitioner Healthcare Foundation, “NPs are ideal clinicians to provide the range and scope of services offered in these settings.” In a recent white paper, the Foundation stated, “With advanced clinical skills grounded in a nursing background and a holistic approach to health care, including a health-promotion perspective, NPs are well-suited and legally able to deliver these services.”

Using the clinics as a triage point, NPs also steer patients to the services they may need elsewhere while providing education and preventive care. “The benefit of the job for me is being able to influence positive health behaviors and to be a resource for patients as they navigate the health-care system,” says May Hang, an NP and manager of operations at a dozen MinuteClinics located in CVS drugstores in and around Detroit. “It feels really good to know that we are part of the solution” to the country’s health-care problems, she adds.

Jan Towers, director of health policy for the American Academy of Nurse Practitioners (AANP), agrees. The clinics are “clearly a great way to open doors for people who don’t have access to care. For example, a mother whose child has an ear infection or a person with a pain that needs to be evaluated doesn’t have to wait a day or two. An NP can examine them and get people to the right place, if the clinic cannot manage the condition itself.”

But NPs and PAs may need more than medical skills to succeed at a clinic. “Typically, you’re there by yourself, or maybe there’s one other person, like a medical assistant,” according to Catherine Wisner, an NP and former MinuteClinic vice president of operations and clinical quality, who is now a senior health fellow in the Office of the U.S. Surgeon General. “You do it all. You greet the patient, take all the insurance information, and collect the payment at the end of the visit, so you need an appreciation of the business side and the customer-service side. You’re the face of the company. Patients can choose to go somewhere else next time, and you want her to come back. It’s a different mindset [than purely clinical].”

Asked if a pace of 10-15 minutes per visit is difficult for a single practitioner to maintain, Wisner points out that the time frame is only “an average guideline. The amount of time per visit is very self-limiting because people come in with specific complaints. If a visit takes more than 15 minutes, that’s OK because other patients, like someone coming in for a tetanus shot, will take less than 15 minutes.”

“You’re more on your own.”

Independence is one of the main attractions the clinics hold for NPs and PAs. “It’s a more autonomous environment for NPs than working inside a physician’s office or in a hospital alongside other practitioners. You are more on your own,” observes Kevin Letz, an NP at the Allergy and Asthma Center in Fort Wayne, Ind., which used to own and operate clinics in SuperValue stores.

Jill Englund, a PA at MinuteClinic in Minneapolis and St. Paul, adds, “What I like best is the ability to practice independently. We’re able to contact a supervising physician immediately if needed, but most of the time, we’re the sole practitioner at the clinic, and it allows for a very autonomous practice.”

Most clinics employ about four NPs or PAs, each with flexible scheduling, Wisner reports. Twelve-hour shifts a couple of days a week are not unusual and can be very attractive. “I can work longer hours three days a week, and then have time off during the week to spend with my two small children,” Englund says.

The corporations that run clinics would not disclose salary ranges, but Hansen-Turton said pay scales at least meet the national average of $75,000 a year plus benefits for NPs. The national average income of PAs is around $80,000 a year. “All clinics are competitive to that average market salary, and many probably pay more to attract NPs,” she notes. “They understand the importance of getting NPs to be part of this model of health care.”

Still, not every NP or PA will be comfortable working in a clinic setting. “Because of the restrictions on services, some NPs feel they are dumbing down the profession,” says Letz. “We’re trained to do much more than the clinics provide.”

Englund adds that the same holds true for PAs. “Some PAs may find the scope of clinic practice limited,” she says. “If a practitioner is looking to treat complicated cases, then a retail clinic setting is not a good fit.”

A shot at management

The explosive growth will, however, create unprecedented opportunities for clinicians, both on the front lines and in the managerial suites. “As nurses working in a hospital or physician’s practice, we are used to being managed,” Letz says. “But in this business, NPs are being empowered.”

“As a manager, what I enjoy most is being a part of a leadership team creating a culture that is supportive and nurturing and grooming NPs for success. We’re offering career opportunities that have never existed before,” says Hang.

Nurse practitioners set standards for convenient-care clinics

“We’re on staff, we’re in top management,” echoes Wisner, who rose through the ranks at MinuteClinic from providing care at a clinic to corporate vice president. “In terms of roles for NPs, the sky’s the limit.” She pointed to Sandy Ryan, chief NP officer for Take Care Health Systems as a “great example of an NP on a leadership team to develop strategy for an organization. All companies should have NP participation at that level.” Take Care operates 50 clinics in Walgreens drugstores in the Midwest and Eckerd drugstores in Pittsburgh.

Some NPs, like Letz, take leadership to the ultimate level as entrepreneurs. For example, Juliet Santos is president and chief executive officer of her own company, Early Solutions Clinic. It has outlets in five Meijer supermarket/ department stores throughout Michigan.

Hansen-Turton expects the convenient-care clinic trend to raise the profile of nursing in general. “This model of care shows nursing professionals how to get out of hospitals and demonstrates the opportunity available to nurses with advanced degrees,” she says. “It makes advanced practitioners more visible, driving up interest in the nursing profession and among nursing students.”

The clinics offer much more opportunity for NPs than PAs, according to Bob Blumm, president of the American College of Clinicians, which promotes the mutual interests of the two professions.

That’s because of state laws which set the “ratios of collaboration” between NPs, PAs, and physicians.

Every clinic has a physician who provides oversight, so the staff has someone available for consultation, said Blumm, a former Long Island, N.Y., manager of operations for MinuteClinic. In New York, the ratio of collaboration is four NPs to one physician and two PAs to one physician, he reports. As a result, clinics hire more NPs than PAs.

Apply this checklist

What should you look for in a clinic, if you’re looking for a job?
• “Ask if there are NPs on the management team,” Wisner advises. “What is the career ladder? How well are NP voices being heard in the organization?”
• Make sure the AANP guidelines are being followed.
• Inquire about quality standards, such as the Joint Commission on Accreditation of Healthcare Organizations, and the maintenance standards set by the Occupational Safety & Health Administration, Clinical Laboratory Improvement Amendments, and the Americans with Disabilities Act.
• “Examine the business itself, and find out if it is stable financially. You may see some companies begin to fold because they run out of capital,” warns Letz, whose own clinics went under in 2003 for that reason.

Hansen-Turton doesn’t foresee a shakeout in the next few years, but she does see change. “There will be an evolution in the industry, with different models,” she says. “We’re already seeing that with the CVS purchase of MinuteClinic. Now some hospitals see an opportunity in opening a convenient-care clinic.”

Ms. Dembrow is a senior editor with The Clinical Advisor.

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