S AMDT 1104

S 1104 IS

To amend the Public Health Service Act to establish the Nurse-Managed Health Clinic Investment program, and for other purposes.

May 20, 2009

Mr. INOUYE (for himself, Mr. ALEXANDER, Mr. AKAKA, and Mr. KAUFMAN) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

To amend the Public Health Service Act to establish the Nurse-Managed Health Clinic Investment program, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘Nurse-Managed Health Clinic Investment Act of 2009’.

SEC. 2. FINDINGS AND PURPOSE.

(a) Findings- Congress makes the following findings:

(1) Nurse-managed health clinics (referred to in this section as ‘NMHCs’) offer their patients primary care and wellness services based on the nursing model, which emphasizes the protection, promotion, and optimization of health along with the prevention of illness, and the alleviation of suffering in conjunction with diagnosis and treatment. Nurses are advocates and educators providing care for individuals, families, communities, and populations.

(2) More than 200 NMHCs are currently in operation across the United States. Such clinics record over 2,000,000 client encounters annually.

(3) NMHCs offering primary care services meet the Institute of Medicine’s definition of safety-net provider by providing care regardless of their patients’ ability to pay. A substantial share of the patient mix is made up of uninsured individuals, Medicaid recipients, State Children’s Health Insurance Program recipients, and other vulnerable populations. A recent study funded by the Centers for Medicare & Medicaid Services reported that more than 45 percent of the payor mix for NMHCs is uninsured, and 37 percent are Medicaid recipients.

(4) NMHC patients are very diverse. According to recent data, 46 percent of NMHC patients are Caucasian, 29 percent are African-American, and another 20 percent are Latino.

(5) Approximately 133,000,000 people in the United States (45 percent of the population) have at least 1 chronic disease. These diseases account for 81 percent of hospital admissions, 91 percent of all prescriptions filled, and 76 percent of all physician visits. About 75 percent of health care spending in the United States is related to chronic care. Chronic disease management programs have the potential to reduce costs and improve outcomes for chronically ill patients. NMHCs providing wellness services strengthen the health care safety-net by expanding access to chronic disease management services for geriatric and medically underserved populations.

(6) NMHCs offering primary care provide a medical home for medically underserved individuals, and are viable partners with the Federal Government to reduce health disparities. They provide a full range of health care services, including primary care, wellness services, and behavioral health care to the residents of rural and urban underserved communities. Because NMHCs are often located in public housing developments, senior living arrangements, schools, and community centers, they help remove barriers preventing access to care and are instrumental in addressing and eliminating the factors contributing to health disparities.

(7) NMHCs offering wellness services reinforce the medical home concept by providing a critical first level of care for populations living in rural areas with limited access to physicians and other primary care providers. NMHC patients participating in wellness services are connected to a medical home through established referral networks.

(8) As new strategies for increasing health coverage are implemented, utilization of nurse-managed health clinics offering both primary care and wellness services will help meet the increased demand arising from newly covered individuals while alleviating current primary care physician shortages.

(9) In spite of their numerous benefits, NMHCs of all types have limited access to both Federal and State funding. Initially, many NMHCs were established through grants from the Division of Nursing of the Health Resources and Services Administration (referred to in this paragraph as the ‘Division of Nursing’). Soon after their inception, NMHC directors recognized their patients had a desperate need for primary care and wellness services, a need that continues. To meet that need, NHMCs across the country have expanded their mission to focus on increasing access to primary care and wellness services the medically underserved populations, while still maintaining their role as clinical sites for nursing education. Available sources of Division of Nursing grant funding cannot accommodate the increased cost associated with caring for the uninsured and medically underserved populations that has accompanied the expanding focus of nurse-managed care. As a result, 50 percent of the NMHCs established between 1993 and 2007 have had to close. Such clinics frequently are the only source of health care for their patients, and such closures have left thousands without health care.

(10) In recognition of the growing needs of NMHCs, in Senate Report 109-103, Congress called on the Bureau of Primary Health Care (BPHC) to ‘consider establishing a grant program . . . that would support the establishment or expansion of nurse practice arrangements commonly referred to as nurse-managed health centers . . .’. The goal of this Act is to comply with the language of such Senate Report by establishing a grant program within BPHC that is a better fit for the changing role of NMHCs. The program will give NMHCs access to a stable source of funding, further enabling them to expand primary care and wellness services in underserved communities, while reducing the level of health disparities that vulnerable populations throughout the Nation face.

(b) Purpose- It is the purpose of this Act to fund the development and operation of nurse-managed health clinics to--

(1) provide comprehensive and accessible primary health care and wellness services to vulnerable populations living in the Nation’s medically underserved communities; and

(2) reduce the level of health disparities experienced by vulnerable populations.

SEC. 3. NURSE-MANAGED HEALTH CLINICS.

Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the following:

‘PART S--NURSE-MANAGED HEALTH CLINIC PROGRAM

‘SEC. 399JJ. GRANTS TO NURSE-MANAGED HEALTH CLINICS.

‘(a) Definition; Establishment of Criteria- In this section:

‘(1) NURSE-MANAGED HEALTH CLINIC OR ‘NMHC’- The term ‘nurse-managed health clinic’ or ‘NMHC’ means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and is associated with a school, college, university, or department of nursing, federally qualified health center, or an independent nonprofit health or social services agency.

‘(2) MEDICALLY UNDERSERVED POPULATIONS- The term ‘medically underserved population’ has the meaning given such term in section 330(b)(3).

‘(3) VULNERABLE POPULATION- The term ‘vulnerable population’ means a population that lacks access to adequate primary care or suffers from increased health disparities due to factors such as health, age, race, ethnicity, sex, insurance status, income level, or ability to communicate effectively.

‘(4) BEHAVIORAL HEALTH CARE SERVICES- The term ‘behavioral health care services’ means health care related to adult, family, and pediatric emotional health and well-being and consists of identifying, assessing, and defining mental health problems and developing a plan of care, which may include psychopharmacological management, education about specific mental illnesses, or basic counseling services that are furnished by qualified health care professionals.

‘(5) COMPREHENSIVE PRIMARY HEALTH CARE SERVICES- The term ‘comprehensive primary health care services’ means health care related to adult, family, and pediatric health and consisting of adult health, pediatrics, obstetrics, or gynecology services that are furnished by nurse practitioners, physician assistants, physicians, nurse midwives, clinical nurse specialists, other advanced practice nurses, or other qualified health care professionals. In addition to primary care services, specific services may include--

‘(A) preventive health services;

‘(B) prenatal and perinatal services;

‘(C) appropriate cancer screening;

‘(D) well-child services;

‘(E) immunizations against vaccine-preventable diseases;

‘(F) screenings for elevated blood lead levels;

‘(G) screening for communicable diseases;

‘(H) cholesterol screenings;

‘(I) pediatric eye and ear screenings to determine the need for vision and hearing correction;

‘(J) emergency medical services;

‘(K) diagnostic laboratory and radiologic services;

‘(L) care navigation services;

‘(M) pharmaceutical services, as may be appropriate for each clinic; and

‘(N) voluntary family planning.

‘(6) WELLNESS SERVICES- The term ‘wellness services’ means any health-related service or intervention, not including primary care, which is designed to reduce identifiable health risks and increase healthy behaviors intended to prevent the onset of disease or lessen the impact of existing chronic conditions by teaching more effective management techniques that focus on individual self-care and patient-driven decisionmaking. Specific services may include--

‘(A) chronic disease self-management training;

‘(B) health screenings relating to hypertension, diabetes, cancer, HIV, lead exposure, and other chronic conditions;

‘(C) health and patient education;

‘(D) immunizations against vaccine-preventable diseases;

‘(E) outreach and home visiting services;

‘(F) environmental health risk reduction services;

‘(G) case management services;

‘(H) interpretation and translation services;

‘(I) weight control programs;

‘(J) smoking cessation programs;

‘(K) physical activity and fitness programs involving geriatric, youth, and other vulnerable populations;

‘(L) occupational safety and health; and

‘(M) cognitive behavioral services.

‘(b) Authority To Award Grants- The Secretary shall award grants for the cost of the operation of NMHCs that meet the requirements of this section.

‘(c) Applications- To be eligible to receive a grant under this section, an entity shall--

‘(1) be a NMHC; and

‘(2) submit to the Secretary an application at such time, in such manner, and containing--

‘(A) an assurance that the NMHC provides direct access to client-centered nursing services with access to other health care services and that nurses are the major service providers at the NMHC;

‘(B) evidence that an advanced practice nurse (‘APN’) holds an executive management position within the organizational structure of the NMHC and that an APN has direct responsibility for overseeing the daily operations of the NMHC;

‘(C) an assurance that the NMHC will continue to provide comprehensive primary care services or wellness services for the duration of the grant period;

‘(D) an assurance that the nurse-managed health clinic will establish, not later than 90 days after receiving a grant under this section, a community advisory committee composed of individuals, a majority of whom are being served by the clinic, the purpose of which is to provide input into the nurse-managed health clinic decisionmaking process;

‘(E) an assurance that the NMHC will demonstrate the receipt of non-Federal matching funds equaling at least 20 percent of the Federal portion of any grant awarded under this section, and evidence that the necessary matching funds will be acquired not later than 180 days after receiving the grant; and

‘(F) an assurance that the NMHC will provide care regardless of the insurance status or income of a patient.

‘(d) Waiver of Requirements- The Secretary may, upon a showing of good cause, waive any aspect of the matching funds requirement described in subsection (c)(2)(E).

‘(e) Use of Funds-

‘(1) IN GENERAL- Funds awarded under a grant under this section may be used for the provision of primary care services and wellness services, for the management of NMHC programs, for the payment of salaries for NMHC personnel, and for providing training for the provision of required health services. Funds may also be used for acquiring and leasing buildings and equipment (including the cost of amortizing the principle of, and paying interest on, loans for such buildings and equipment).

‘(2) AMOUNT- The amount of any grant made in any fiscal year to a NMHC shall be determined by the Secretary, taking into account--

‘(A) the financial need of the NMHC;

‘(B) State, local, and other operational funding provided to the NMHC; and

‘(C) other factors as determined appropriate by the Secretary.

‘(f) Technical Assistance-

‘(1) IN GENERAL- The Secretary shall establish a program through which the Secretary shall provide (either through the Department of Health and Human Services or by grant or contract) technical and other assistance to NMHCs to assist such clinics in meeting the requirements of this section. In determining appropriate providers to assist in offering technical assistance, the Secretary shall consider whether the provider has demonstrated the capacity to effectively address the unique needs of NMHCs.

‘(2) TECHNICAL SERVICES- Services provided under this section may include necessary technical and nonfinancial assistance, including fiscal and program management assistance, training in fiscal and program management, operational and administrative support, and the provision of information to NMHC regarding the various resources available under this section and how those resources can best be used to meet the health needs of the communities served by NMHCs.

‘(g) Evaluation- The Secretary shall develop and implement a plan for evaluating NMHCs funded under this section. Such evaluations shall monitor and track the performance of the grantee as well as the quality of the services that are provided under the grant.

‘(h) Authorization of Appropriations- For the purposes of carrying out this section, there are authorized to be appropriated $50,000,000 for fiscal year 2010, and such sums as may be necessary for each of fiscal years 2011 through 2014.’.