Roughly one in six Americans live in a rural area, but only 10% of primary care physicians (PCPs) practice in these communities. Physicians in rural areas are older on average, suggesting that the rural PCP shortages will intensify in coming years. In the face of a looming PCP shortage nationwide, some researchers advocate team-based care—defined as collaborative care provided by groups of physician and nonphysician clinicians—as one way to accommodate the care needs of an aging population in rural and urban areas alike. Nonphysician clinicians, such as nurse practitioners (NPs) and physician assistants (PAs), are already integral members of the rural primary care workforce. Compared to physicians, NPs and PAs are more than twice as likely to locate in rural areas. As a result, NPs and PAs provide 1 in 6 office visits in rural areas, compared to 1 in 10 in urban areas. For this reason, rural areas provide an opportunity to learn about the structure, functioning, and quality of care provided by primary care teams.

While considerable research has focused on the productivity and quality of care provided by individual clinician types, data limitations have hampered researchers' ability to study team-based provision of care. In particular, few data are currently available on rural-urban differences in the structure and quality of care provided by primary care teams. This analysis will address that gap by describing the size, clinician types, specialty composition, and workload allocation of primary care teams based on rural versus urban practice location. It will also quantify associations between attributes of primary care teams and the quality of care they provide. By providing detailed information on the organization, workflow, and care quality of primary care teams in rural communities, this project will inform the policy conversation regarding workforce adequacy and access to high-quality primary care.

This project is national in scope and will have relevance for policymaking at the federal, state, local, and institutional levels. We will analyze two national datasets, one of clinician characteristics and the second comprising all-payer claims and electronic health record data. We plan to compare attributes of primary care teams—including size (total number of clinicians and size of patient panel) and composition (ratio of physician to nonphysician clinicians)—in rural and urban communities; describe workload allocation (number of visits and total time scheduled for patient care) and complexity (number, type, and severity of patient diagnoses) among primary care team members and compare by rural/urban location; assess patterns of high-quality care delivery within and between primary care teams; and identify characteristics of successful team-based primary care structure in rural settings that may inform the shift to patient-centered team-based care nationwide.

Publications

• Nurse Practitioner Autonomy and Complexity of Care in Rural Primary Care
  Journal Article
  University of Minnesota Rural Health Research Center
  Date: 07/2020
  The increasing number of nurse practitioners (NPs) in the rural U.S. has the potential to help alleviate primary care shortages. Using a nationwide source of claims and Electronic Health Record data from 2017, this study constructs measures of NP clinical autonomy and complexity of care.
• Rural and Urban Differences in Primary Care Pain Treatment by Clinician Type
  Policy Brief
  University of Minnesota Rural Health Research Center
  Date: 04/2020
  In this brief, we compare 2017 opioid prescribing rates among physicians and nurse practitioners within primary care practices and how these differ for rural versus urban areas.