Politics related to implementing policy mandates in a rural nurse-managed clinic

This presentation will describe reflections on the politics of implementing policy mandates in a rural nurse-managed clinic with increasingly limited fiscal and human resources. The clinic, which is located in a Medically Underserved Area (MUA) and Health Professional Shortage Area (HPSA), has been in operation since 1996. In addition to providing access to health care for uninsured residents, the clinic provides exemplary clinical learning experiences for undergraduate and graduate nursing students. Staff members are focused on disease prevention and health promotion activities for clients who typically have multiple chronic diseases. The primary funding source for clinic operations, the State Department of Health, continues to mandate that the number of client encounters increase. Staff members understand the importance of comprehensive care in chronic disease management and resist focusing solely on numbers, thus requiring them to reduce the length of time spent with clients and compromise the quality of care delivered. In addition, current policy mandates that only nurse practitioner visits count, creating frustration for other nursing staff members who understand that considerable time is necessary to deliver optimal care in activities that do not count, such as health education essential when dispensing medications provided by the Prescription Assistance Program. Additional examples of the politics involved in implementing policy mandates, such as a new state mandate initiated by the Governor's office to address weight loss and physical fitness that requires staff to create a personal computerized profile for each clinic client, will be described. Coupled with these issues related to increased policy mandates is the reality of decreased funding for social services so vital to the residents in this geographic area which has one of the lowest median family incomes in the state. This requires the clinic staff to assume greater involvement in securing needed ancillary services and acting as the safety net for their clients. Strategies to deal with the politics of addressing increased policy mandates with decreased fiscal and human resources will be discussed.