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There is a great deal of geographic variation in where primary care providers work. About 65 million Americans live in areas that are officially identified as primary care shortage areas according to the Health Resources and Services Administration (HRSA) (Rieselbach et al., 2010). For example, while one in five U.S. residents live in rural areas, only one in ten physicians practice in those areas (Bodenheimer and Pham, 2010). A 2006 survey of all 846 federally funded community health centers (CHCs) by Rosenblatt and colleagues (2006) found that 46 percent of direct care providers in rural CHCs were nonphysician clinicians, including nurse practitioners, nurse midwives, and physician assistants, in urban clinics, the figure was 38.9 percent. The contingent of physicians was heavily dependent on international medical graduates and loan forgiveness programs. Even so, the vacancies for physicians totaled 428 full-time equivalents (FTEs), while those for nurses totaled 376 FTEs (Rosenblatt et al., 2006). Expansion of programs that encourage health care providers to practice primary care, especially those from underrepresented and culturally diverse backgrounds, will be needed to keep pace with the demand for community-based care. For further discussion of variation in the geographic distribution of primary care providers, see the section on expanding access to primary care in Chapter 3. tadalafil vs viagra forum aside how to take cialis for ed or cost prednisone 20 mg ago what is the difference between tadalafil and tadalafil.

In 2008, the Government Accountability Office determined that there were few projections of the future need for primary care providers, and those that existed were substantially limited (Steinwald, 2008). Arguably, it is simpler to project the future supply of health professionals than to project future demand for their services. It is difficult to predict, for example, the pattern of increased demand for primary care after full implementation of the ACA adds 32 million newly insured people to the health care system. Will there be a short, marked spike in demand, or will the surge be of longer duration that leaves more time to adapt? Finally, the health care system is widely understood to be a complex system, one in which responses to internal and external actions are sometimes predictable and sometimes not. Health care experts repeatedly encourage health professionals to understand the system’s dynamics so they can be more effective in their individual jobs and help shape the larger system’s ability to adapt successfully to changes and improve outcomes. In a field as intensively knowledge driven as health care, however, no one individual, group, or discipline can have all the answers. A growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals to generate successful solutions in complex, knowledge-driven systems (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Nurses must cultivate new allies in health care, government, and business and develop new partnerships with other clinicians, business owners, and philanthropists to help realize the vision of a transformed health care system. Many nurses have heard this call to develop new partnerships in a culture of collaboration and cooperation. However, the committee found no evidence that these initiatives have achieved the scale necessary to have an impact throughout the health care system. More intentional, large-scale initiatives of this sort are needed. These efforts must be supported by research that addresses such questions as what new models of leadership are needed for the increasingly knowledge-intensive health care environment and when collaboration is most appropriate (Singh and Fleming, 2010). tadalafil farmacias similares mexico none comparison viagra levitra cialis and under euro pharmacy tadalafil. Reflecting the charge to the committee, the purpose of this report is to consider reconceptualized roles for nurses, ways in which nursing education system can be designed to educate nurses who can meet evolving health care demands, the role of nurses in creating innovative solutions for health care delivery, and ways to attract and retain well-prepared nurses in a variety of settings. The report comes at a time of opportunity in health care resulting from the passage of the Affordable Care Act (ACA), which will provide access to care for an additional 32 million Americans. In the preceding chapters, the committee has described both barriers and opportunities in nursing practice, education, and leadership. It has also discussed the workforce data needed to guide policy and workforce planning with respect to the numbers, types, and mix of professionals that will be required in an evolving health care environment.

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