II 

111TH CONGRESS 

1ST SESSION S. 1104 

To amend the Public Health Service Act to establish the Nurse-Managed 

Health Clinic Investment program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 20, 2009 

Mr. INOUYE (for himself, Mr. ALEXANDER, Mr. AKAKA, and Mr. KAUFMAN) 

introduced the following bill; which was read twice and referred to the 

Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Public Health Service Act to establish the 

Nurse-Managed Health Clinic Investment program, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Nurse-Managed 

5 Health Clinic Investment Act of 2009’’. 

6 SEC. 2. FINDINGS AND PURPOSE. 

7 (a) FINDINGS.—Congress makes the following find8 ings: 


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1 (1) Nurse-managed health clinics (referred to in 

2 this section as ‘‘NMHCs’’) offer their patients pri3 mary care and wellness services based on the nurs4 ing model, which emphasizes the protection, pro5 motion, and optimization of health along with the 

6 prevention of illness, and the alleviation of suffering 

7 in conjunction with diagnosis and treatment. Nurses 

8 are advocates and educators providing care for indi9 viduals, families, communities, and populations. 

10 (2) More than 200 NMHCs are currently in op11 eration across the United States. Such clinics record 

12 over 2,000,000 client encounters annually. 

13 (3) NMHCs offering primary care services meet 

14 the Institute of Medicine’s definition of safety-net 

15 provider by providing care regardless of their pa16 tients’ ability to pay. A substantial share of the pa17 tient mix is made up of uninsured individuals, Med18 icaid recipients, State Children’s Health Insurance 

19 Program recipients, and other vulnerable popu20 lations. A recent study funded by the Centers for 

21 Medicare & Medicaid Services reported that more 

22 than 45 percent of the payor mix for NMHCs is un23 insured, and 37 percent are Medicaid recipients. 

24 (4) NMHC patients are very diverse. According 

25 to recent data, 46 percent of NMHC patients are 


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1 Caucasian, 29 percent are African-American, and 

2 another 20 percent are Latino. 

3 (5) Approximately 133,000,000 people in the 

4 United States (45 percent of the population) have at 

5 least 1 chronic disease. These diseases account for 

6 81 percent of hospital admissions, 91 percent of all 

7 prescriptions filled, and 76 percent of all physician 

8 visits. About 75 percent of health care spending in 

9 the United States is related to chronic care. Chronic 

10 disease management programs have the potential to 

11 reduce costs and improve outcomes for chronically ill 

12 patients. NMHCs providing wellness services 

13 strengthen the health care safety-net by expanding 

14 access to chronic disease management services for 

15 geriatric and medically underserved populations. 

16 (6) NMHCs offering primary care provide a 

17 medical home for medically underserved individuals, 

18 and are viable partners with the Federal Govern19 ment to reduce health disparities. They provide a 

20 full range of health care services, including primary 

21 care, wellness services, and behavioral health care to 

22 the residents of rural and urban underserved com23 munities. Because NMHCs are often located in pub24 lic housing developments, senior living arrange25 ments, schools, and community centers, they help reVerDate Nov 24 2008 01:44 May 22, 2009 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1104.IS S1104

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1 move barriers preventing access to care and are in2 strumental in addressing and eliminating the factors 

3 contributing to health disparities. 

4 (7) NMHCs offering wellness services reinforce 

5 the medical home concept by providing a critical 

6 first level of care for populations living in rural 

7 areas with limited access to physicians and other 

8 primary care providers. NMHC patients partici9 pating in wellness services are connected to a med10 ical home through established referral networks. 

11 (8) As new strategies for increasing health cov12 erage are implemented, utilization of nurse-managed 

13 health clinics offering both primary care and 

14 wellness services will help meet the increased de15 mand arising from newly covered individuals while 

16 alleviating current primary care physician shortages. 

17 (9) In spite of their numerous benefits, NMHCs 

18 of all types have limited access to both Federal and 

19 State funding. Initially, many NMHCs were estab20 lished through grants from the Division of Nursing 

21 of the Health Resources and Services Administration 

22 (referred to in this paragraph as the ‘‘Division of 

23 Nursing’’). Soon after their inception, NMHC direc24 tors recognized their patients had a desperate need 

25 for primary care and wellness services, a need that 


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1 continues. To meet that need, NHMCs across the 

2 country have expanded their mission to focus on in3 creasing access to primary care and wellness services 

4 the medically underserved populations, while still 

5 maintaining their role as clinical sites for nursing 

6 education. Available sources of Division of Nursing 

7 grant funding cannot accommodate the increased 

8 cost associated with caring for the uninsured and 

9 medically underserved populations that has accom10 panied the expanding focus of nurse-managed care. 

11 As a result, 50 percent of the NMHCs established 

12 between 1993 and 2007 have had to close. Such 

13 clinics frequently are the only source of health care 

14 for their patients, and such closures have left thou15 sands without health care. 

16 (10) In recognition of the growing needs of 

17 NMHCs, in Senate Report 109–103, Congress called 

18 on the Bureau of Primary Health Care (BPHC) to 

19 ‘‘consider establishing a grant program . . . that 

20 would support the establishment or expansion of 

21 nurse practice arrangements commonly referred to 

22 as nurse-managed health centers . . .’’. The goal of 

23 this Act is to comply with the language of such Sen24 ate Report by establishing a grant program within 

25 BPHC that is a better fit for the changing role of 


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1 NMHCs. The program will give NMHCs access to a 

2 stable source of funding, further enabling them to 

3 expand primary care and wellness services in under4 served communities, while reducing the level of 

5 health disparities that vulnerable populations 

6 throughout the Nation face. 

7 (b) PURPOSE.—It is the purpose of this Act to fund 

8 the development and operation of nurse-managed health 

9 clinics to— 

10 (1) provide comprehensive and accessible pri11 mary health care and wellness services to vulnerable 

12 populations living in the Nation’s medically under13 served communities; and 

14 (2) reduce the level of health disparities experi15 enced by vulnerable populations. 

16 SEC. 3. NURSE-MANAGED HEALTH CLINICS. 

17 Title III of the Public Health Service Act (42 U.S.C. 

18 241 et seq.) is amended by adding at the end the fol19 lowing: 

20 ‘‘PART S—NURSE-MANAGED HEALTH CLINIC 

21 PROGRAM 

22 ‘‘SEC. 399JJ. GRANTS TO NURSE–MANAGED HEALTH CLIN23 ICS. 

24 ‘‘(a) DEFINITION; ESTABLISHMENT OF CRITERIA.— 

25 In this section: 


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1 ‘‘(1) NURSE-MANAGED HEALTH CLINIC OR

2 ‘NMHC’.—The term ‘nurse-managed health clinic’ or 

3 ‘NMHC’ means a nurse-practice arrangement, man4 aged by advanced practice nurses, that provides pri5 mary care or wellness services to underserved or vul6 nerable populations and is associated with a school, 

7 college, university, or department of nursing, feder8 ally qualified health center, or an independent non9 profit health or social services agency. 

10 ‘‘(2) MEDICALLY UNDERSERVED POPU11 LATIONS.—The term ‘medically underserved popu12 lation’ has the meaning given such term in section 

13 330(b)(3). 

14 ‘‘(3) VULNERABLE POPULATION.—The term 

15 ‘vulnerable population’ means a population that 

16 lacks access to adequate primary care or suffers 

17 from increased health disparities due to factors such 

18 as health, age, race, ethnicity, sex, insurance status, 

19 income level, or ability to communicate effectively. 

20 ‘‘(4) BEHAVIORAL HEALTH CARE SERVICES.— 

21 The term ‘behavioral health care services’ means 

22 health care related to adult, family, and pediatric 

23 emotional health and well-being and consists of iden24 tifying, assessing, and defining mental health prob25 lems and developing a plan of care, which may inVerDate Nov 24 2008 01:44 May 22, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1104.IS S1104

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1 clude psychopharmacological management, education 

2 about specific mental illnesses, or basic counseling 

3 services that are furnished by qualified health care 

4 professionals. 

5 ‘‘(5) COMPREHENSIVE PRIMARY HEALTH CARE

6 SERVICES.—The term ‘comprehensive primary 

7 health care services’ means health care related to 

8 adult, family, and pediatric health and consisting of 

9 adult health, pediatrics, obstetrics, or gynecology 

10 services that are furnished by nurse practitioners, 

11 physician assistants, physicians, nurse midwives, 

12 clinical nurse specialists, other advanced practice 

13 nurses, or other qualified health care professionals. 

14 In addition to primary care services, specific services 

15 may include— 

16 ‘‘(A) preventive health services; 

17 ‘‘(B) prenatal and perinatal services; 

18 ‘‘(C) appropriate cancer screening; 

19 ‘‘(D) well-child services; 

20 ‘‘(E) immunizations against vaccine-pre21 ventable diseases; 

22 ‘‘(F) screenings for elevated blood lead lev23 els; 

24 ‘‘(G) screening for communicable diseases; 

25 ‘‘(H) cholesterol screenings; 


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1 ‘‘(I) pediatric eye and ear screenings to de2 termine the need for vision and hearing correc3 tion; 

4 ‘‘(J) emergency medical services; 

5 ‘‘(K) diagnostic laboratory and radiologic 

6 services; 

7 ‘‘(L) care navigation services; 

8 ‘‘(M) pharmaceutical services, as may be 

9 appropriate for each clinic; and 

10 ‘‘(N) voluntary family planning. 

11 ‘‘(6) WELLNESS SERVICES.—The term ‘wellness 

12 services’ means any health-related service or inter13 vention, not including primary care, which is de14 signed to reduce identifiable health risks and in15 crease healthy behaviors intended to prevent the 

16 onset of disease or lessen the impact of existing 

17 chronic conditions by teaching more effective man18 agement techniques that focus on individual self-care 

19 and patient-driven decisionmaking. Specific services 

20 may include— 

21 ‘‘(A) chronic disease self-management 

22 training; 

23 ‘‘(B) health screenings relating to hyper24 tension, diabetes, cancer, HIV, lead exposure, 

25 and other chronic conditions; 


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1 ‘‘(C) health and patient education; 

2 ‘‘(D) immunizations against vaccine-pre3 ventable diseases; 

4 ‘‘(E) outreach and home visiting services; 

5 ‘‘(F) environmental health risk reduction 

6 services; 

7 ‘‘(G) case management services; 

8 ‘‘(H) interpretation and translation serv9 ices; 

10 ‘‘(I) weight control programs; 

11 ‘‘(J) smoking cessation programs; 

12 ‘‘(K) physical activity and fitness programs 

13 involving geriatric, youth, and other vulnerable 

14 populations; 

15 ‘‘(L) occupational safety and health; and 

16 ‘‘(M) cognitive behavioral services. 

17 ‘‘(b) AUTHORITY TO AWARD GRANTS.—The Sec18 retary shall award grants for the cost of the operation of 

19 NMHCs that meet the requirements of this section. 

20 ‘‘(c) APPLICATIONS.—To be eligible to receive a grant 

21 under this section, an entity shall— 

22 ‘‘(1) be a NMHC; and 

23 ‘‘(2) submit to the Secretary an application at 

24 such time, in such manner, and containing— 


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1 ‘‘(A) an assurance that the NMHC pro2 vides direct access to client-centered nursing 

3 services with access to other health care serv4 ices and that nurses are the major service pro5 viders at the NMHC; 

6 ‘‘(B) evidence that an advanced practice 

7 nurse (‘APN’) holds an executive management 

8 position within the organizational structure of 

9 the NMHC and that an APN has direct respon10 sibility for overseeing the daily operations of the 

11 NMHC; 

12 ‘‘(C) an assurance that the NMHC will 

13 continue to provide comprehensive primary care 

14 services or wellness services for the duration of 

15 the grant period; 

16 ‘‘(D) an assurance that the nurse-managed 

17 health clinic will establish, not later than 90 

18 days after receiving a grant under this section, 

19 a community advisory committee composed of 

20 individuals, a majority of whom are being 

21 served by the clinic, the purpose of which is to 

22 provide input into the nurse-managed health 

23 clinic decisionmaking process; 

24 ‘‘(E) an assurance that the NMHC will 

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1 ing funds equaling at least 20 percent of the 

2 Federal portion of any grant awarded under 

3 this section, and evidence that the necessary 

4 matching funds will be acquired not later than 

5 180 days after receiving the grant; and 

6 ‘‘(F) an assurance that the NMHC will 

7 provide care regardless of the insurance status 

8 or income of a patient. 

9 ‘‘(d) WAIVER OF REQUIREMENTS.—The Secretary 

10 may, upon a showing of good cause, waive any aspect of 

11 the matching funds requirement described in subsection 

12 (c)(2)(E). 

13 ‘‘(e) USE OF FUNDS.— 

14 ‘‘(1) IN GENERAL.—Funds awarded under a 

15 grant under this section may be used for the provi16 sion of primary care services and wellness services, 

17 for the management of NMHC programs, for the 

18 payment of salaries for NMHC personnel, and for 

19 providing training for the provision of required 

20 health services. Funds may also be used for acquir21 ing and leasing buildings and equipment (including 

22 the cost of amortizing the principle of, and paying 

23 interest on, loans for such buildings and equipment). 


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1 ‘‘(2) AMOUNT.—The amount of any grant made 

2 in any fiscal year to a NMHC shall be determined 

3 by the Secretary, taking into account— 

4 ‘‘(A) the financial need of the NMHC; 

5 ‘‘(B) State, local, and other operational 

6 funding provided to the NMHC; and 

7 ‘‘(C) other factors as determined appro8 priate by the Secretary. 

9 ‘‘(f) TECHNICAL ASSISTANCE.— 

10 ‘‘(1) IN GENERAL.—The Secretary shall estab11 lish a program through which the Secretary shall 

12 provide (either through the Department of Health 

13 and Human Services or by grant or contract) tech14 nical and other assistance to NMHCs to assist such 

15 clinics in meeting the requirements of this section. 

16 In determining appropriate providers to assist in of17 fering technical assistance, the Secretary shall con18 sider whether the provider has demonstrated the ca19 pacity to effectively address the unique needs of 

20 NMHCs. 

21 ‘‘(2) TECHNICAL SERVICES.—Services provided 

22 under this section may include necessary technical 

23 and nonfinancial assistance, including fiscal and pro24 gram management assistance, training in fiscal and 

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1 tive support, and the provision of information to 

2 NMHC regarding the various resources available 

3 under this section and how those resources can best 

4 be used to meet the health needs of the communities 

5 served by NMHCs. 

6 ‘‘(g) EVALUATION.—The Secretary shall develop and 

7 implement a plan for evaluating NMHCs funded under 

8 this section. Such evaluations shall monitor and track the 

9 performance of the grantee as well as the quality of the 

10 services that are provided under the grant. 

11 ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—For the 

12 purposes of carrying out this section, there are authorized 

13 to be appropriated $50,000,000 for fiscal year 2010, and 

14 such sums as may be necessary for each of fiscal years 

15 2011 through 2014.’’. 

Æ 


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