The Vanderbilt Model
Metro Nashville Public Schools, Gaylord Opryland Resort and Mercury Courts housing all have one thing in common. Each is home to a Vanderbilt clinic that is managed by faculty nurse practitioners and offers health care to diverse populations. Vanderbilt University School of Nursing (VUSN) provides faculty for the clinics and operates them in partnership with Vanderbilt University Medical Center (VUMC).
In all, the VUSN/VUMC partnership operates 10 clinics throughout Middle Tennessee. They include clinics for private employers and four sites at Metro Nashville Public Schools, one of which has just moved into a new facility at district headquarters. VUSN midwives manage clinics at the West End Women’s Health Center and in the Melrose neighborhood, and staff a Baby+Company birth center. The Melrose clinic, newly renamed Melrose Primary Care, has recently added primary care services, turning it into a location offering both midwifery services and primary care for women.
Vanderbilt pioneered the concept of nurse-managed clinics locally in the early 1990s. It is poised to add as many as 10 more nurse-managed clinics in a variety of locations throughout Middle Tennessee in the next three years to meet the demands of a growing and aging population, said C. Wright Pinson, MBA, M.D., Deputy CEO and Chief Health System Officer for VUMC.
“The monies that are available to pay for that expanding demand are limited,” he said. “We have to look for new ways to deliver health care. Nurse practitioners represent an opportunity to accomplish that favorably. Working with physicians or independently with a supervising physician, nurse practitioners can serve those needs in a cost-effective fashion.”
Part of tomorrow’s health care model
Pam Jones, DNP, R.N., Senior Associate Dean for Clinical and Community Partnerships for the School of Nursing, said consumers are driving the market for nurse-managed clinics, looking for convenience and cost-effective care.
The VUSN/VUMC partnership works like this: VUSN faculty staff the clinics, many of them as employees of VUMC. Nursing students gain opportunities to apply their learning in the community, and VUMC gains the expertise of nurse practitioners educated with the latest in advanced practice. Jones works as a team with Linda Norman, DSN, R.N., the Valere Potter Menefee Professor of Nursing and Dean of the School of Nursing; Marilyn Dubree, MSN, R.N., NE-BC, VUMC Executive Chief Nursing Officer; and April Kapu, DNP, APRN, Associate Nursing Officer for the VUMC Office of Advanced Practice.
“This is part of the health care model of the future, and we are helping drive that here,” Jones said. “Everybody is trying to figure out how to add advanced practice nurses and advanced practice clinicians into their complements, and we really know how to do that here at Vanderbilt through this longtime partnership of the Medical Center and the School of Nursing.”
In addition to her VUMC role, Dubree also sits on VUSN’s executive committee. “I think the partnership is extraordinary in what it is not. It is not a health system looking just to create services as a business model. It’s not just a school of nursing looking to create academic student placement sites,” she said. “It is a partnership between a health system and a school of nursing to provide excellence in clinical care and evidence-based practice in those sites.
“You can only do that when you have a partnership between a school of nursing and a health system. It is an opportunity for us to work together to create access and opportunities for innovations in practice and to improve the value proposition for patients, payers and communities.”
Jones said the deepening partnership between VUSN and VUMC will allow Vanderbilt advanced practice nurses to take 25 years of expertise with nurse-managed centers to a wider audience.
“The School of Nursing practices have a long history of serving some of Nashville’s most vulnerable populations. We will continue the proud tradition of serving underserved populations with these very effective models,” she said. “But we will also take those practices to a broader audience.”
In determining where to place the clinics, Jones said Vanderbilt would consider where there is a need for additional primary care providers and populations that benefit from the comprehensive, holistic approach that is the hallmark of advanced practice nursing.
“We will work in collaboration with the Medical Center to identify sites that are needed and execute on rapid cycle implementation,” she said. “We are very excited to bring this great model to more families and communities.”
Evolution of nurse-run clinics
Nursing leaders are building on a strong 25-year track record of opening and managing clinics. Vanderbilt opened its first nurse-managed clinic in 1991 during an era of brisk change for VUSN. Then-Dean Colleen Conway-Welch was revolutionizing nursing practice and the school transitioned into a graduate school from being an undergraduate program that also offered some master’s degrees. The role of the nurse practitioner was still in its infancy, and VUSN leaders were looking for a way to have an impact in the community, said Bonnie Pilon, Ph.D., Professor of Nursing, Emerita. Pilon was instrumental in launching the first clinic and continued to oversee VUSN clinics until 2015.
That first clinic was in the Vine Hill housing development in South Nashville, identified by leadership as an area of need. Vanderbilt incorporated a nonprofit organization, University Community Health Services (UCHS), to operate Vine Hill. VUSN faculty nurses directed the clinic, starting with just one full-time and one-part time nurse practitioner, but expanding quickly.
“The seeds that were planted at Vine Hill have grown into mighty oaks,” said Pilon, who recently returned from a yearlong sabbatical researching the history and culture of nurse-managed clinics nationwide. “It was a tremendous start to the rest of the story.”
From there, Vanderbilt began offering clinic services to schools in lower income neighborhoods—starting in 1995 with a location at Fall Hamilton School, which serves the children of the Vine Hill neighborhood. Additional clinics soon opened at Park Avenue Elementary and Taylor Stratton Elementary.
In 2004, Vanderbilt expanded into providing clinic services for private employers, providing services for the Sanford Corporation in Lewisburg, Tennessee. The company paid for employees and their families to use the clinic for free. “That was a relatively new idea for nurse-managed health centers nationally in the mid 2000s,” Pilon said. “We were real pioneers in doing this.”
The clinic had immediate results, Pilon said. One patient survived neck cancer because clinicians spotted a lump on his neck and he was sent to a specialist for treatment. Another man was referred to cardiology for his symptoms and underwent a five-vessel bypass surgery the next day. “He would have died,” Pilon said.
In 2007, the UCHS clinics transitioned from the university to an independent community agency in order to qualify for federally qualified health center status, a key source of federal funding.
VUSN continued to seek opportunities to open nurse-managed clinics where the need arose. In 2012, it opened the Clinic at Mercury Courts in collaboration with Urban Housing Solutions, a nonprofit that provides housing to the homeless.
Around 1999, VUSN expanded into offering midwifery services and comprehensive OB-GYN care with the West End Women’s Health Center on West End Avenue. Nurse-midwives see patients there and women deliver at Vanderbilt University Adult Hospital or a new option, Baby+Company, a freestanding private birth center that opened in Nashville in 2015. VUSN nurse-midwives provide care at that center in a collaboration with VUMC and Baby+Company. VUSN midwives also can be found at the Melrose Primary Clinic on Franklin Pike in Nashville and at Cole Family Practice in Hermitage.
In addition to providing cost-effective care, nurse-managed clinics offer VUSN students opportunities to engage with diverse populations. That experience is invaluable to VUMC, as nurses trained at VUSN often become the nurses who practice within the Vanderbilt Health Affiliated Network.
“It gives the student a window to the community,” Pilon said. “It gives them a window to health-disparate challenges and meeting those challenges. It gives them a window to different cultures, different ethnicities, different economic situations. We do it because we’re a caring profession and our mission is to improve the health and well-being of people.”
VUSN was one of the first schools to place nurse practitioners and advanced practice nurses into collaborative practices with physicians and within agencies. Its innovative PreSpecialty programs allow students multiple entry options to go from a bachelor’s degree to a master’s or doctoral degree. U.S. News & World Report ranks its DNP program as the No. 11 program in the country and its MSN at No. 15.
“The Vanderbilt University School of Nursing is a gem for a number of reasons,” Pinson said. “The focus that they have had on many different master’s level programs and doctoral-level programs is nationally renowned, and their ranking demonstrates that. The nursing school represents a tremendous strength to Vanderbilt University Medical Center and to the entire Vanderbilt Health Affiliated Network across the state of Tennessee.”
Empowering advanced practice
Supporting the continued growth in nurse-managed clinics is the rapidly expanding field of advanced practice nurses (APRNs), with about 930 at VUMC. APRN roles encompass certified registered nurse anesthetists, certified nurse practitioners, certified nurse-midwives and clinical nurse specialists. All APRNs are educated in nationally accredited programs, clinically trained and board-certified in their area of practice.
VUSN’s Jones works with community leaders to identify needs for new practices, and collaborates with VUMC’s Kapu on business models for advanced practice as well as on creating leaders who will direct the next generation of clinics.
“In acknowledgement of the need for leadership structures that empower advanced practice, there is a nationwide trend to develop and appoint leaders who are APRNs and physician assistants,” Jones said. “VUSN and VUMC are national leaders in this arena through our innovative advanced practice leadership structure, which includes the Office of Advanced Practice, educating leaders through the Doctorate of Nursing Practice program and active mentorship of emerging leaders.
“Vanderbilt is one of the few places in the country that all advanced practice registered nurses and physician assistants have a link back to a leader who is an advanced practice registered nurse or physician assistant. And from the literature and our experience, we believe that’s crucial to creating a practice environment that’s supportive for them.”
Kapu said that clinics will continue to grow because they meet consumer needs for accessible, affordable and high quality care.
“The comprehensive, holistic approach to care delivered through our nurse faculty clinics unquestionably meets today’s consumer demand. ‘Clinic’ is increasingly becoming a broad term to mean primary care delivery through multiple access points such as after-hours clinics, walk-in clinics, house calls and virtual care. In addition, these clinics—Melrose is a great example—are increasing convenience and affordability by bundling care services in a single location.”
Local and national impact
The advantages of nurse-managed clinics are multifold, Jones said. “From a Medical Center standpoint, we have this asset of being able to partner the School of Nursing with the Medical Center to create these clinics and create a practice environment that really allows people to thrive and grow and develop and meet the needs of the population,” she said. “And in a population health model, the holistic training of advanced practice nurses is very much in keeping with how you create quality and decrease cost in our system over time.”
Pilon is able to stand back and look at Vanderbilt’s nurse-managed clinics with an informed eye. “The Vanderbilt School of Nursing is seen nationally as a leader in this area,” Pilon said. “I think not only have we impacted health locally and regionally, which we certainly have, but we’ve influenced the development of a number of other sites. We’ve made a difference here, but also nationally. Our voice has been heard.”
by Matt Batcheldor