In a First for California, Nurse Practitioners to Deliver Primary Care without Physician Supervision

One of the important roles of a nurse practitioner like Jennifer Ballard-Hernandez is to educate patients about their health conditions. Photo credit: Mariah Castaneda


Jennifer Ballard-Hernandez, 39, sat inside the Long Beach VA Hospital’s Cardiac Clinic, holding a plastic replica of a human heart, her fingers crossing over the ventricles and atriums. It’s one of the props she uses to educate patients about their health conditions, a critical part of her job as a nurse practitioner.

“We try to keep [patients] out of the hospital if they don’t need to go there,” she explained.

Nurse practitioners, who hold masters or doctorate degrees in nursing, can diagnose patients, prescribe medication and admit patients to the hospital. Yet in California, they typically work under the supervision of medical doctors despite their years of training.  Ballard-Hernandez is an exception, one of the few nurse practitioners now working with full practice authority in the state of California.

Experts hope that allowing practice authority for nurse practitioners will help alleviate the long wait times that have plagued VA patients. Photo credit: Mariah Castaneda

Thanks to a change in federal rules, however, by February 2018, all 76 of Ballard-Hernandez’s fellow nurse practitioners at the VA hospital will be credentialed to practice and treat patients, providing services typically performed by a primary care physician, without a supervising doctor. 

In Sept. 2017, the Department of Veterans Affairs Long Beach Health Care System became the first California facility to implement a federal law that allows nurse practitioners, including Ballard-Hernandez, to work with full practice authority within Veterans Affairs Hospitals. This rule supersedes existing state restrictions and is implemented at the discretion of every VA hospital.

Cory Ramsey, Associate Director for Patient Care Services/Nurse Executive for the Long Beach VA hospital, stressed that allowing practice authority for nurse practitioners was meant to “increase our capacity to provide quality, efficient, effective and safe primary care.” 

Long wait times have been well-documented through news outlets and the VA’s own record of wait times. Nationally, about 6 percent of VA patients must wait more than a month to see a doctor. 

Richard Beam, spokesperson for the Long Beach VA hospital, said the consequences of not providing care soon enough, especially those with mental health needs, can be serious.

“For them to be sick any longer than necessary can have a ripple effect on their employment or schooling,” Beam said. “If their condition escalates or spirals, they are more likely to do something that lends itself to a bad outcome. If we tell someone who is in acute immediate need right now [they must wait] two weeks, they may start to self-medicate.”

For Ballard-Hernandez the change has meant less paperwork and more time to give patients care. Before the change, Ballard-Hernandez said, “we [had] to have physicians go and co-sign forms, physicians that have never may have even seen the patient, sign off on things. These are mundane, outdated rules and regulations that are not reflective of our education or training.”

Nurse practitioners with full practice authority have led to lower emergency room admissions and more routine check-ups in states where nurse practitioners are allowed to practice independently.

Ballard-Hernandez is one of the few nurse practitioners now working with full practice authority in the state of California.Photo credit: Mariah Castaneda

According to Andrew Acosta, a political consultant in Sacramento who has worked on behalf of full practice authority for nurse practitioners, this setup complicates access to care in rural California, areas where primary care shortages are common. Nurse practitioners, who might alleviate the shortage, must find a supervising doctor before they can treat patients.

California’s ratio of clinicians to residents is only slightly below national average, but rural areas like the Inland Empire have only 39 primary care doctors for every 100,000 people.

One argument against full practice authority is that nurse practitioners do not receive the same training as doctors, and allowing them to practice as primary care providers would be detrimental to patients. In a press release, shortly after the VA decision to allow nurse practitioners full practice authority last year, the American Academy of Family Physicians President John Meigs said that the new rule impeded on state rights and would harm veterans.

According to Ballard-Hernandez, the decision to give nurse practitioners full practice authority at the Long Beach VA hospital was “well received” and was voted in by the majority of medical staff. Ballard-Hernandez said the success was due in part to communication in defining clearly what is in the scope of a nurse practitioner.

Ballard-Hernandez said, “We want to partner with our physician colleagues so patients get the health care they deserve. The routine everyday tasks, we’re happy to handle those, and let the physicians do the high level specialty care.”

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