A Registered Nurse-Led Model in Primary Care by Optimizing Health Maintenance

A Quality Improvement Project

Kelly Sullivan, DNP, MSN, RN, NE-BC; Kevin Shah, MD, MBA; Blanca Iris Padilla, PhD, MBA-C, MSN, APRN, FNP-BC, FAANP


Nurs Econ. 2022;40(3):130-135. 

In This Article

Abstract and Introduction


The economic burden of community acquired pneumonia in the United States is well documented, and the elderly population is at greater risk for infection, hospitalization, and death. There are innovative methods that can be implemented in the primary care setting that can lead to improved health maintenance, preventative services, and patient outcomes for Medicare beneficiaries. RN-led models are an effective method for improving preventative care and addressing health maintenance gaps.


Pneumonia is a well-documented cause of morbidity and mortality in the United States. In 2017, 1.3 million people were diagnosed with pneumonia in an emergency department setting (Centers for Disease Control and Prevention [CDC], 2022b). Pneumococcal disease is caused by the bacteria streptococcus pneumonia (CDC, 2020), is the most isolated pathogen, and accounts for more than 25% of the community-acquired pneumonia (CAP) cases worldwide (Lanks et al., 2019). Streptococcus pneumonia was noted as the most detected bacteria with an incidence rate five times as high in adults 65 years or older versus younger adults (Jain et al., 2015).

According to the CDC, both pneumonia and influenza, together, are noted to be the ninth leading cause of death in the United States (Heron, 2021). A substantial increase in the incidence of CAP occurs with age ranging between 18.2 per 1,000 person-years in those ages 65–69, to 52.3 per 1,000 person-years in those ages 85 and over (Wagner & Weinberger, 2020). With the increase in life expectancy in the aging population, along with the presence of comorbid conditions, it is important to protect this segment of the population with primary prevention such as established recommendation of the pneumococcal vaccine (Office of Disease Prevention and Health Promotion, 2022).

As the population ages, the U.S. healthcare system will face new challenges in caring for older adults. According to He and colleagues (2016), the number of older adults – aged 65 and older – will double between the years 2025 and 2050. Rowe and colleagues (2016) highlighted the challenges of the healthcare system in providing high quality services to the growing elderly population and offers strategies for improvement. Some of those strategies include alternative care delivery models and enhancing the elder care workforce, which is vital in preparing for better health in the aging population (Rowe et al., 2016). A promising approach is utilizing a team-based care model using registered nurses (RNs) in expanded roles performing annual wellness visits (AWVs). This approach can increase access and preventative care including vaccinations.

The Centers for Medicare & Medicaid Services (CMS) covers AWVs for Medicare beneficiaries. Introduced in 2011 as part of the Patient Protection and Affordable Care Act, AWVs provide Medicare patients the opportunity to develop a personalized plan of wellness care which includes age-specific screenings, tests, and other preventative services such as vaccines (CMS, 2022). AWVs have increased over the years (8% in 2011 to 19% in 2015), with pneumococcal vaccine rates also increasing (Shen et al., 2017).

AWVs may be performed by a variety of providers including physicians, advance practice providers, pharmacists, or other team members who are working under the direct supervision of a physician (such as a RN) (CMS, 2022). The benefits of having a RN conducting an AWV includes reducing risk for illness, hospitalizations, and fragmented care. Additionally, RNs can perform patients' health risk assessments and make recommendations on preventative health maintenance, including the pneumococcal vaccine. The pneumococcal vaccines have been improved over time and one dose of the pneumococcal conjugate vaccine protects 75 in 100 against invasive pneumococcal disease, and 45 in 100 against pneumococcal pneumonia (CDC, 2022a).

With a projection of the older population outpacing the younger populations over the next 30 years, coupled by a declining number of primary care providers, healthcare organizations must examine alternative care delivery models. Additionally, the United States is approaching a unique crossroads affecting the delivery of health care, including a shift to value-based care, as a strategy for continued healthcare reform and new models of care – including RNs in team-based care. Team-based care may provide cost-effective care while improving efficiency and quality (Schottenfeld et al., 2016). There is a growing body of literature on the RNs' ability to contribute to increasing access and quality cost-effective care in the ambulatory care setting (Haas & Swan, 2014). In the 2016 position statement, the American Academy of Ambulatory Care Nursing (AAACN) highlighted RNs must practice at the top of their license, education, and expertise to affect quality and cost through patient engagement, care coordination, enhanced teamwork, resource reduction, improved access, and quality and outcome improvement (AAACN, 2016).