McCrory-Watson was uninsured, and Mitchell went to great lengths to get financial assistance for two new drugs aimed at addressing her medical problems. As a result, McGrory-Watson is now Hep C-free, and she hopes a drug she’s taking for PTSD will quell the lingering effects of being gang-raped as a teenager and witnessing a brutal stabbing as an adult.

There’s something about Mitchell that might surprise you. She’s not a doctor; she’s a nurse. A nurse practitioner (NP), to be precise. But McGrory-Watson insists that the care Mitchell provides is every bit as good as she would get from a physician. “In my opinion, people shouldn’t worry about being treated by a nurse practitioner; they should be glad,” she says. “Nichole brings the holistic approach of truly knowing me and not just seeing a list of symptoms on a page.”

Steve Hamm Photo.

Nichole Mitchell, a nurse practitioner, provides primary care at the Community Health Center, Inc., in Middletown.

There are likely to be many more people like Nichole Mitchell in our future. The number of medical students seeking careers as primary care providers is lagging while nurse practitioners overwhelmingly choose careers in primary care. Meanwhile, demand for primary care providers is growing due to the opioid crisis, the aging population and an increase in chronic illnesses.

Already, the federal government’s Health Resources and Services Administration estimates that 13,800 additional primary care physicians are needed to meet current demand. The shortage could grow to 50,000 by 2030, according to a study prepared for the Association of American Medical Colleges (AAMC). And, if the promise of universal health care becomes a reality, it could top 95,000.

In Connecticut, 3,786 of the state’s 12,341 active physicians are in primary care, according to the AAMC. To maintain today’s status quo, Connecticut will have to add more than 400 primary care physicians by 2030, according to analysis by The Robert Graham Center.

Advocates for physician education propose policy changes that could help persuade more doctors to seek careers in primary care, including increases in loan forgiveness. At the same time, some medical schools, including Quinnipiac University’s Frank H. Netter School of Medicine, have programs that focus on primary care.

Still, nurse practitioners are already a major component of the primary care workforce, and health care leaders are counting on them to increasingly take responsibility for comprehensive primary care. A study published last year in the New England Journal of Medicine estimates that more than half of the primary care providers nationwide in 2030 will be NPs or physician assistants (PAs). The number of NPs is expected to grow 47 percent by 2025. “It has become clear that you can’t improve health care in the United States unless you unleash the power of nursing,” says Ann Kurth, dean of Yale School of Nursing.

Nurse practitioners typically complete a baccalaureate degree in nursing and a two-year master’s degree compared to seven years of post-baccalaureate training for physicians.

Michael Melford Photo/CHC

NP Nicole Seagriff exams a patient.

Connecticut health care leaders are counting on improved primary care to head off more serious medical problems and more costly treatments—pushing a team approach where physicians, nurse practitioners, physician assistants, behavioral therapists and others work collaboratively. “We want to meet all the patients’ needs at the door, and nurse practitioners play an important role,” says Vicki Veltri, executive director of the Connecticut Office of Health Strategy.

In Connecticut, seasoned NPs are permitted to evaluate patients, diagnose illnesses and prescribe medications—all without physician supervision. The ranks of advanced practice registered nurses grew from 1,772 in 1998 to 5,382 last year, according to the Department of Public Health. Most of them are nurse practitioners.

For her part, CHC’s Mitchell objects to nurse practitioners being viewed as fill-ins for doctors. “Family nurse practitioners didn’t go to school to be physician extenders but rather independent clinicians. We stand on our own two feet and do consistently great work,” she says.

In fact, studies show that the quality of care provided by NPs typically matches or exceeds that of physicians—and costs are lower because of the salary differences. An article published in 2017 in the journal Medical Care concluded that NPs matched the quality of care and outperformed doctors when it came to providing health counseling.

At CHC, which serves 145,000 patients across Connecticut, roughly 50 percent of primary care providers in its health centers are nurse practitioners. They provide pediatric, adult, family and women’s health services, plus behavioral health services. In Fairfield County, primary care clinics are located in Norwalk, Stamford and Danbury. “NPs have always been equal partners here, both in clinical practice and in leadership,” says Margaret Flinter, senior vice president and clinical director, who began as CHC’s first NP in 1980.

Many primary care physicians in the state welcome the expanding role of nurse practitioners, though some express concerns. The Charlotte-Hungerford Multispecialty Group in Torrington employs a number of nurse practitioners, yet Stacy Taylor, MD, a primary care physician there, says, “You can’t say that all NPs can work without supervision. We really focus on teamwork. We’re all available to help each other out.”

Connecticut permits licensed NPs who have been practicing in the state for at least three years under a physician’s supervision to work independently and to the full extent of their training. This is called full practice authority. Twenty-one other states have similar regulations. The others are more restrictive.

CHC has been a national leader in providing advanced training for nurse practitioners. Flinter established the nation’s first postgraduate residency program in 2007, and now there are 60-some NP residency programs around the country. “We are asking NPs to be at the center of primary care, and we want to give them the opportunity for intensive postgraduate training that is focused on clinical complexity and on a high-performance model of care,” says Flinter.

Steve Hamm Photo.

Patients wait to check-in at the Community Health Center, Inc., Middletown.

The organization is also a pioneer in using technology to help NPs—along with physicians and PAs—provide the best care for their patients. One program, eConsult, enables primary care providers to interact with specialists via a digital platform. They receive answers to their questions about patients in 48 to 72 hours—rather than requiring patients to wait months for appointments with specialists. They also get expert advice on the best treatment options. “It’s a tremendous learning opportunity for us. We connect with experts and learn from them,” says Nicole Seagriff, a nurse practitioner at CHC’s Norwalk office.

CHC’s program is now running for 12 specialties, and it’s cutting the need for face-to-face specialist consults by 30 percent. It saves the Medicaid system $84 per CHC member per month.

While some states balk at granting full practice authority, the dam holding back NPs seems to be bursting. The Veterans Administration Health Service and other federal agencies have given NPs and nurse midwives independence in all 50 states. They and others, including retail clinics, such as CVS, are hiring them aggressively.

“We want to see changes in the way health care is provided in this country,” says Monte Wagner, a nurse practitioner who works at the VA in West Haven and is an officer of the Connecticut Advance Practice Registered Nurse Society. “Too many states don’t allow full practice authority. That’s the biggest change we need to see.”

“This most recent work on veterans’ access to primary care expands further the litany of VA health care deficiencies and weaknesses that we have identified over the years,” Debra Draper, director of the Government Accountability Office’s (GAO) health-care team, said in testimony to the House Committee on Veterans’ Affairs. “As of April 1, 2016, there were about 90 GAO recommendations regarding veterans’ health care awaiting action by VHA … (including) more than a dozen recommendations to address weaknesses in the provision and oversight of veterans’ access to timely primary and specialty care, including mental health care.

“Until VHA can make meaningful progress in addressing these and other recommendations,” she added, “the quality and safety of health care for our nation’s veterans is at risk.”

On average, the wait time nationally for primary care appointments was seven days as of April 1.

The new GAO report looked at wait times for newly enrolled veterans seeking primary care appointments at six VA medical centers around the country. Among a random sample of 180 of those veterans, 60 who requested care had not been seen at all by primary care providers, in some cases because the VA never contacted them or because they were left off an eligibility list in error. For the other 120 who requested care and were seen, the average time between their initial requests that the VA contact them for appointments and the dates they were seen ranged from 22 to 71 days.

While slightly more than half were seen by providers in less than 30 days, the veterans’ experiences varied widely, even within the same medical center, with 12 veterans waiting more than 90 days, the report says.

The most recent national data from the VA shows that, on average, the wait time for primary care appointments as of April 1, 2016, was seven days – down from 7.94 days a year ago.

In Connecticut, the West Haven VA shows a wait time for primary care of just 1.72 days – relatively low nationally. Overall, more than 97 percent of veterans seeking health care in West Haven get appointments scheduled within 30 days, the data show.

Other VAs have much longer waits. The average wait for a primary care appointment in Fayetteville, NC, is 52.76 days; in White City, Oregon, 51.14 days; and in Dover, Tenn., 48 days.

Nationally, wait times for specialty care average 10 days, and for mental health care, four days. At the West Haven VA, wait times are 4.86 days for specialty care and 2.25 days for mental health care, the most recent data show.

The GAO report found that two factors generally impacted veterans’ wait times: Appointments were not always available when veterans wanted to be seen, and “weaknesses in VA medical scheduling practices” led to some veterans not being contacted on a timely basis.

“Officials at each of the six medical centers in our review told us that they have difficulty keeping up with the demand for primary care appointments for new patients because of shortages in the number of providers, or lack of space due to rapid growth in the demand for these services,” the GAO said.

Also, the report says, the VA does not properly record the time that veterans wait to be seen, starting from the veterans’ “preferred dates” for appointments, instead of the dates that veterans initially contact the VA to schedule appointments. These “scheduling errors, such as incorrectly revising preferred dates when rescheduling appointments, understated the amount of time veterans waited to see providers,” the GAO said.

For example, one veteran mentioned in the report applied for VA health care benefits in December 2014, which included a request to be contacted for an initial appointment. The VA medical center contacted the veteran to schedule a primary care appointment 43 days later. When making the appointment, the medical center recorded the veteran’s preferred date as March 1, 2015, and the veteran saw a provider on March 3, 2015. Although the medical center’s data showed the veteran waited two days to see a provider, the total amount of time that elapsed from the veteran’s request until the veteran was seen was actually 76 days.

The GAO recommended that the VA monitor the full amount of time that veterans wait to see a primary care provider and improve contact with veterans seeking appointments – recommendations that the VA accepted.

Zachary Paul-Allen Greenough, 28, of Uncasville, was participating in a residential program where he was free to leave the hospital campus during the day, according to Pamela Redmond, spokesperson for the West Haven VA hospital. She said, as a result, Greenough could have obtained the drugs “anywhere.”

She said the VA would not comment on the cause of Greenough’s death, which occurred on Dec. 22, 2015.

She said an investigation by the hospital’s Patient Safety Program has been completed, but the results are not yet available. The VA Office of Inspector General (OIG) in Washington is also conducting an investigation of the death, she said.

The hospital informed the Inspector General’s office of the death, Redmond said.

She said privacy laws prevent her from disclosing what specific program Greenough was participating in, but she did say that he was not in a program for post traumatic stress disorder.

The type of program Greenough was enrolled in requires participants to be at the hospital during the evening and overnight. During the day, they are allowed to leave so they can participate in treatment programs, and seek employment and housing, Redmond said.

VA officials informed the Connecticut Congressional delegation of the death in a Dec. 24 conference call with staff members and follow up emails on Dec. 28, according to a “Statement on Untimely Death” released by the hospital.

U.S. Sen. Richard Blumenthal, ranking member of the Senate Armed Services Committee, has asked that the Inspector General’s investigation include specifics of the death, staffing and security issues, and whether the program Greenough was participating in was the appropriate treatment for him.

In a letter to Deputy Inspector General Linda Holiday, Blumenthal wrote “Any misuse or abuse of drugs, especially causing death to a veteran, is inexcusable. I am sure you share my outrage and that your investigation will reflect the urgency of this issue.”

The hospital’s statement reported that its own police department and police dogs make routine rounds of inpatient areas to search for illegal substances, that the hospital asks the Inspector General’s Office to investigate suspected cases of illegal drugs, and that VA police and criminal investigators “collaborate frequently” with state and local police on criminal drug cases.

“Patient safety is our highest priority,” the VA hospital statement says.

According to his obituary, Greenough was born in New London and lived with an aunt and uncle. A funeral service took place Jan. 16 in Waterford.

“It’s going to be 120 over 60,” Swirsky says, as Hutchinson inflates the cuff on the meter on his left arm. “Close,” she said, “124 over 60.”

Derek Torrellas Photo.

Nurse Jeanette Hutchinson checks veteran Bob Swisky’s vital signs.

In Connecticut, there are 209,882 veterans, according to the most-recent U.S. census data, and 29.4 percent are over the age of 75. This group forms the core of veterans with chronic medical issues who are targeted by a VA program to treat them in their own homes.

Most of the patients in the VA’s Home Based Primary Care (HBPC) program are like Swirsky, who is bed-bound and not able to easily get to the West Haven VA Hospital. He enrolled in the HBPC program in August. Swirsky’s daughter, Mindy Hart, said, “It is tremendously tiring for him to get into a car, or even just to move around.”

Home Based Primary Care, “is a team approach in which we have multiple disciplines that come out to the house and visit our veterans who typically have a difficult time getting into the hospital to see their provider on a regular basis,” said Hutchinson.

The team is comprised of the program director, physicians, psychiatrists, nurses, social workers, registered dieticians, physical therapists, clinical pharmacists, and program support staff.

Prospective patients are veterans who are already registered in the VA health care system. Veterans are referred to HBPC by the hospital, or their doctors, or sometimes veterans request the service themselves, said Aileen O’Connell, HBPC program director. A registered nurse assesses referrals.

Bob Swirsky talks about the VA care program.

Swirsky, 96, lives just a few miles from the West Haven VA and falls within the territory HBPC covers. Across the state, the general guideline is 30 miles or 30 minutes from the VA facilities in West Haven or Newington, or from one of the community-based outpatient clinics, located in New London, Winsted and Waterbury.

August Palmer of Stratford was recommended to the program after receiving an implanted defibrillator. “I’m 93,” he said, “I can hardly walk.” Staying at home to obtain care has put less of a burden on Palmer’s children. “My son David takes me – or my daughter Mary – and so they don’t work and everything,” he said. “That’s not fair.”

Pawcatuck resident and Army veteran Donald MacLean, 67, has been an HBPC patient for about four years, after he suffered a fall while being treated for tumors, and he was transferred to a nursing home.

He still needed care when he was released to his house, MacLean’s wife, Leslie, explained over the phone. The problem was, she couldn’t provide it.

“When they first started coming, I had nothing,” she said. “Cindy [Anderson, MacLean’s HBPC nurse] walked in the door and immediately she ordered a hospital bed, she ordered stuff for the showers. She got everything I needed that I had no idea how to get, or that I even could get.”

The nurse visits her husband once a month to check on him and review all his medication, ordering more if needed. Maclean said she was under a great deal of stress around the time her husband began receiving care at home. When Anderson noticed, she asked permission to bring one of the team’s social workers to meet her.

“I think that the other side of home-based care is the social worker,” MacLean said. She’s grateful for the social worker’s personal assistance, she said, especially when needing help completing any paperwork relating to the VA or insurance.

It costs the VA about $16,000 to take care of a veteran at home, not including other non-HBPC expenses incurred by the VA and Medicare for these patients. The program has resulted in a 36 percent reduction in the number of days veterans spend in a hospital once they begin receiving home care. This decrease leads to an about 12 percent reduction in combined VA and Medicare annual cost per patient, according to the VA.

In fiscal 2015, a daily average of 444 patients were enrolled in Home Based Primary Care in the state; the number has remained steady the past several years. Nationally, the average daily total is 35,982 patients, an increase from 27,102 in fiscal year 2011, according to the VA.

Derek Torrellas Photo.

Nurse Jeanette Hutchinson checks veteran Bob Swirsky.

In November, Stars and Stripes reported on an increasing number of veterans on waiting lists for home care. Five facilities – Los Angeles, White City, Ore.; Puget Sound, Wash.; Richmond, Va.; and Beckley, W.Va. — accounted for more than half of the 2,566 waiting veterans.

In Connecticut, there is no waiting list, according to the care team. Referrals are immediately addressed and sent to the nurse that covers the patient’s geographic area.

For Swirsky, the benefits are numerous.

“You let us have our dignity,” he said to Hutchinson. “It’s being in your own bed, being in your own environment, and people who you know come in and visit you. That’s important.”

Derek Torrellas a C-HIT intern and recent graduate of Southern Connecticut State University.

The report — which comes as the U.S. Department of Veterans Affairs grapples with a rise in suicides that claim an estimated 22 veterans’ lives a day — recommends that the VA take action to improve post-discharge follow-up for patients with acute mental health problems.

The VA requires its mental health clinicians to evaluate patients considered at high risk for suicide at least weekly for the 30 days after their discharge from Veterans Health Administration (VHA) mental health care. But of 215 patients whose medical records were examined by the inspector general’s office, 65, or 30 percent, did not receive all of their follow-up evaluations, the report shows. Records of 33 percent of the 215 patients did not contain documentation that a suicide-prevention coordinator or other case manager had made attempts at contact.

“Although MH (mental health) providers scheduled follow-up appointments prior to patient discharge, timely post-discharge MH evaluations were not consistently provided,” the report says. It recommends that the VHA improve efforts to reach out to patients who don’t report to scheduled appointments and document those contact attempts.

Among veterans not deemed at high risk for suicide, 78 percent of the sampled group had some type of mental health evaluation within seven days after discharge, as required by VA policy. But some of those patients received only phone calls and were not evaluated in person or via “telemental health” services within two weeks of discharge.

Also, while VA policy “encourages” facilities to provide follow-up evaluations within 48 hours of discharge, only a quarter of patients received such services. Missed appointments were an added problem, the inspector general’s office said.

Dr. Robert Petzel, the VA’s undersecretary for health, said his department would direct facilities to create “a local patient registry for follow-up on all patients discharged from inpatient mental health units.”  He said the agency also would remind facilities that they need to contact veterans who miss appointments and to document those attempts in patients’ medical records.

The VA has a number of studies and programs underway aimed at suicide prevention, but has been under fire for failing to care for veterans with mental health problems in a timely manner. Every VA medical center now has at least one suicide-prevention coordinator, responsible for tracking patients at risk for self-harm.

At the West Haven VA, a policy is in place requiring follow-up of all veterans deemed at high risk for suicide, to ensure that four visits occur within the first 30 days of discharge, said Maureen Pasko, suicide prevention coordinator for the West Haven facility. Also, she said, clinicians contact veterans who are at high risk when they do not show up for appointments, and document those attempts in the medical record.

The need for follow-up “relates to a potential high-risk period following inpatient admissions,” Pasko said. After the 30-day period, high-risk veterans are seen “as often as clinically indicated, and continue to be monitored by the Suicide Prevention Program.”

The new inspector general’s report prompted U.S. Sen. Barbara Boxer, D-Calif., to send a letter to Secretary of Veterans Affairs Eric Shinseki, urging the VA to ensure that all veterans who have been hospitalized for acute mental illness and deemed at risk for suicide receive the required post-discharge evaluations.

“The OIG report is alarming because VA requirements for follow-up care are clear, yet they are not being followed. This is putting some of our most vulnerable veterans at further risk for self-injury,” she said in a May 6 letter.

Boxer noted that an inspector general’s report from 2010 similarly had found that the VA struggled to ensure veterans discharged from inpatient mental health care received proper follow-up.