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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1104 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Nurse-Managed Health Clinic 
Investment Act of 2009''.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--Congress makes the following findings:
            (1) Nurse-managed health clinics (referred to in this 
        section as ``NMHCs'') offer their patients primary care and 
        wellness services based on the nursing model, which emphasizes 
        the protection, promotion, and optimization of health along 
        with the prevention of illness, and the alleviation of 
        suffering in conjunction with diagnosis and treatment. Nurses 
        are advocates and educators providing care for individuals, 
        families, communities, and populations.
            (2) More than 200 NMHCs are currently in operation across 
        the United States. Such clinics record over 2,000,000 client 
        encounters annually.
            (3) NMHCs offering primary care services meet the Institute 
        of Medicine's definition of safety-net provider by providing 
        care regardless of their patients' ability to pay. A 
        substantial share of the patient mix is made up of uninsured 
        individuals, Medicaid recipients, State Children's Health 
        Insurance Program recipients, and other vulnerable populations. 
        A recent study funded by the Centers for Medicare & Medicaid 
        Services reported that more than 45 percent of the payor mix 
        for NMHCs is uninsured, and 37 percent are Medicaid recipients.
            (4) NMHC patients are very diverse. According to recent 
        data, 46 percent of NMHC patients are Caucasian, 29 percent are 
        African-American, and another 20 percent are Latino.
            (5) Approximately 133,000,000 people in the United States 
        (45 percent of the population) have at least 1 chronic disease. 
        These diseases account for 81 percent of hospital admissions, 
        91 percent of all prescriptions filled, and 76 percent of all 
        physician visits. About 75 percent of health care spending in 
        the United States is related to chronic care. Chronic disease 
        management programs have the potential to reduce costs and 
        improve outcomes for chronically ill patients. NMHCs providing 
        wellness services strengthen the health care safety-net by 
        expanding access to chronic disease management services for 
        geriatric and medically underserved populations.
            (6) NMHCs offering primary care provide a medical home for 
        medically underserved individuals, and are viable partners with 
        the Federal Government to reduce health disparities. They 
        provide a full range of health care services, including primary 
        care, wellness services, and behavioral health care to the 
        residents of rural and urban underserved communities. Because 
        NMHCs are often located in public housing developments, senior 
        living arrangements, schools, and community centers, they help 
        remove barriers preventing access to care and are instrumental 
        in addressing and eliminating the factors contributing to 
        health disparities.
            (7) NMHCs offering wellness services reinforce the medical 
        home concept by providing a critical first level of care for 
        populations living in rural areas with limited access to 
        physicians and other primary care providers. NMHC patients 
        participating in wellness services are connected to a medical 
        home through established referral networks.
            (8) As new strategies for increasing health coverage are 
        implemented, utilization of nurse-managed health clinics 
        offering both primary care and wellness services will help meet 
        the increased demand arising from newly covered individuals 
        while alleviating current primary care physician shortages.
            (9) In spite of their numerous benefits, NMHCs of all types 
        have limited access to both Federal and State funding. 
        Initially, many NMHCs were established through grants from the 
        Division of Nursing of the Health Resources and Services 
        Administration (referred to in this paragraph as the ``Division 
        of Nursing''). Soon after their inception, NMHC directors 
        recognized their patients had a desperate need for primary care 
        and wellness services, a need that continues. To meet that 
        need, NHMCs across the country have expanded their mission to 
        focus on increasing access to primary care and wellness 
        services the medically underserved populations, while still 
        maintaining their role as clinical sites for nursing education. 
        Available sources of Division of Nursing grant funding cannot 
        accommodate the increased cost associated with caring for the 
        uninsured and medically underserved populations that has 
        accompanied the expanding focus of nurse-managed care. As a 
        result, 50 percent of the NMHCs established between 1993 and 
        2007 have had to close. Such clinics frequently are the only 
        source of health care for their patients, and such closures 
        have left thousands without health care.
            (10) In recognition of the growing needs of NMHCs, in 
        Senate Report 109-103, Congress called on the Bureau of Primary 
        Health Care (BPHC) to ``consider establishing a grant program . 
        . . that would support the establishment or expansion of nurse 
        practice arrangements commonly referred to as nurse-managed 
        health centers . . .''. The goal of this Act is to comply with 
        the language of such Senate Report by establishing a grant 
        program within BPHC that is a better fit for the changing role 
        of NMHCs. The program will give NMHCs access to a stable source 
        of funding, further enabling them to expand primary care and 
        wellness services in underserved communities, while reducing 
        the level of health disparities that vulnerable populations 
        throughout the Nation face.
    (b) Purpose.--It is the purpose of this Act to fund the development 
and operation of nurse-managed health clinics to--
            (1) provide comprehensive and accessible primary health 
        care and wellness services to vulnerable populations living in 
        the Nation's medically underserved communities; and
            (2) reduce the level of health disparities experienced by 
        vulnerable populations.

SEC. 3. NURSE-MANAGED HEALTH CLINICS.

    Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) 
is amended by adding at the end the following:

             ``PART S--NURSE-MANAGED HEALTH CLINIC PROGRAM

``SEC. 399JJ. GRANTS TO NURSE-MANAGED HEALTH CLINICS.

    ``(a) Definition; Establishment of Criteria.--In this section:
            ``(1) Nurse-managed health clinic or `nmhc'.--The term 
        `nurse-managed health clinic' or `NMHC' means a nurse-practice 
        arrangement, managed by advanced practice nurses, that provides 
        primary care or wellness services to underserved or vulnerable 
        populations and is associated with a school, college, 
        university, or department of nursing, federally qualified 
        health center, or an independent nonprofit health or social 
        services agency.
            ``(2) Medically underserved populations.--The term 
        `medically underserved population' has the meaning given such 
        term in section 330(b)(3).
            ``(3) Vulnerable population.--The term `vulnerable 
        population' means a population that lacks access to adequate 
        primary care or suffers from increased health disparities due 
        to factors such as health, age, race, ethnicity, sex, insurance 
        status, income level, or ability to communicate effectively.
            ``(4) Behavioral health care services.--The term 
        `behavioral health care services' means health care related to 
        adult, family, and pediatric emotional health and well-being 
        and consists of identifying, assessing, and defining mental 
        health problems and developing a plan of care, which may 
        include psychopharmacological management, education about 
        specific mental illnesses, or basic counseling services that 
        are furnished by qualified health care professionals.
            ``(5) Comprehensive primary health care services.--The term 
        `comprehensive primary health care services' means health care 
        related to adult, family, and pediatric health and consisting 
        of adult health, pediatrics, obstetrics, or gynecology services 
        that are furnished by nurse practitioners, physician 
        assistants, physicians, nurse midwives, clinical nurse 
        specialists, other advanced practice nurses, or other qualified 
        health care professionals. In addition to primary care 
        services, specific services may include--
                    ``(A) preventive health services;
                    ``(B) prenatal and perinatal services;
                    ``(C) appropriate cancer screening;
                    ``(D) well-child services;
                    ``(E) immunizations against vaccine-preventable 
                diseases;
                    ``(F) screenings for elevated blood lead levels;
                    ``(G) screening for communicable diseases;
                    ``(H) cholesterol screenings;
                    ``(I) pediatric eye and ear screenings to determine 
                the need for vision and hearing correction;
                    ``(J) emergency medical services;
                    ``(K) diagnostic laboratory and radiologic 
                services;
                    ``(L) care navigation services;
                    ``(M) pharmaceutical services, as may be 
                appropriate for each clinic; and
                    ``(N) voluntary family planning.
            ``(6) Wellness services.--The term `wellness services' 
        means any health-related service or intervention, not including 
        primary care, which is designed to reduce identifiable health 
        risks and increase healthy behaviors intended to prevent the 
        onset of disease or lessen the impact of existing chronic 
        conditions by teaching more effective management techniques 
        that focus on individual self-care and patient-driven 
        decisionmaking. Specific services may include--
                    ``(A) chronic disease self-management training;
                    ``(B) health screenings relating to hypertension, 
                diabetes, cancer, HIV, lead exposure, and other chronic 
                conditions;
                    ``(C) health and patient education;
                    ``(D) immunizations against vaccine-preventable 
                diseases;
                    ``(E) outreach and home visiting services;
                    ``(F) environmental health risk reduction services;
                    ``(G) case management services;
                    ``(H) interpretation and translation services;
                    ``(I) weight control programs;
                    ``(J) smoking cessation programs;
                    ``(K) physical activity and fitness programs 
                involving geriatric, youth, and other vulnerable 
                populations;
                    ``(L) occupational safety and health; and
                    ``(M) cognitive behavioral services.
    ``(b) Authority To Award Grants.--The Secretary shall award grants 
for the cost of the operation of NMHCs that meet the requirements of 
this section.
    ``(c) Applications.--To be eligible to receive a grant under this 
section, an entity shall--
            ``(1) be a NMHC; and
            ``(2) submit to the Secretary an application at such time, 
        in such manner, and containing--
                    ``(A) an assurance that the NMHC provides direct 
                access to client-centered nursing services with access 
                to other health care services and that nurses are the 
                major service providers at the NMHC;
                    ``(B) evidence that an advanced practice nurse 
                (`APN') holds an executive management position within 
                the organizational structure of the NMHC and that an 
                APN has direct responsibility for overseeing the daily 
                operations of the NMHC;
                    ``(C) an assurance that the NMHC will continue to 
                provide comprehensive primary care services or wellness 
                services for the duration of the grant period;
                    ``(D) an assurance that the nurse-managed health 
                clinic will establish, not later than 90 days after 
                receiving a grant under this section, a community 
                advisory committee composed of individuals, a majority 
                of whom are being served by the clinic, the purpose of 
                which is to provide input into the nurse-managed health 
                clinic decisionmaking process;
                    ``(E) an assurance that the NMHC will demonstrate 
                the receipt of non-Federal matching funds equaling at 
                least 20 percent of the Federal portion of any grant 
                awarded under this section, and evidence that the 
                necessary matching funds will be acquired not later 
                than 180 days after receiving the grant; and
                    ``(F) an assurance that the NMHC will provide care 
                regardless of the insurance status or income of a 
                patient.
    ``(d) Waiver of Requirements.--The Secretary may, upon a showing of 
good cause, waive any aspect of the matching funds requirement 
described in subsection (c)(2)(E).
    ``(e) Use of Funds.--
            ``(1) In general.--Funds awarded under a grant under this 
        section may be used for the provision of primary care services 
        and wellness services, for the management of NMHC programs, for 
        the payment of salaries for NMHC personnel, and for providing 
        training for the provision of required health services. Funds 
        may also be used for acquiring and leasing buildings and 
        equipment (including the cost of amortizing the principle of, 
        and paying interest on, loans for such buildings and 
        equipment).
            ``(2) Amount.--The amount of any grant made in any fiscal 
        year to a NMHC shall be determined by the Secretary, taking 
        into account--
                    ``(A) the financial need of the NMHC;
                    ``(B) State, local, and other operational funding 
                provided to the NMHC; and
                    ``(C) other factors as determined appropriate by 
                the Secretary.
    ``(f) Technical Assistance.--
            ``(1) In general.--The Secretary shall establish a program 
        through which the Secretary shall provide (either through the 
        Department of Health and Human Services or by grant or 
        contract) technical and other assistance to NMHCs to assist 
        such clinics in meeting the requirements of this section. In 
        determining appropriate providers to assist in offering 
        technical assistance, the Secretary shall consider whether the 
        provider has demonstrated the capacity to effectively address 
        the unique needs of NMHCs.
            ``(2) Technical services.--Services provided under this 
        section may include necessary technical and nonfinancial 
        assistance, including fiscal and program management assistance, 
        training in fiscal and program management, operational and 
        administrative support, and the provision of information to 
        NMHC regarding the various resources available under this 
        section and how those resources can best be used to meet the 
        health needs of the communities served by NMHCs.
    ``(g) Evaluation.--The Secretary shall develop and implement a plan 
for evaluating NMHCs funded under this section. Such evaluations shall 
monitor and track the performance of the grantee as well as the quality 
of the services that are provided under the grant.
    ``(h) Authorization of Appropriations.--For the purposes of 
carrying out this section, there are authorized to be appropriated 
$50,000,000 for fiscal year 2010, and such sums as may be necessary for 
each of fiscal years 2011 through 2014.''.
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