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Nurse Practitioner–Physician Comanagement:
A Theoretical Model to Alleviate Primary Care Strain

ABSTRACT
PURPOSE Various models of care delivery have been investigated to meet the
increasing demands in primary care. One proposed model is comanagement of
patients by more than 1 primary care clinician. Comanagement has been inves-
tigated in acute care with surgical teams and in outpatient settings with primary
care physicians and specialists. Because nurse practitioners are increasingly man-
aging patient care as independent clinicians, our study objective was to propose
a model of nurse practitioner–physician comanagement.

METHODS We conducted a literature search using the following key words:
comanagement; primary care; nurse practitioner OR advanced practice nurse.
From 156 studies, we extracted information about nurse practitioner–physician
comanagement antecedents, attributes, and consequences. A systematic review
of the findings helped determine effects of nurse practitioner–physician coman-
agement on patient care. Then, we performed 26 interviews with nurse practitio-
ners and physicians to obtain their perspectives on nurse practitioner–physician
comanagement. Results were compiled to create our conceptual nurse practitio-
ner–physician comanagement model.

RESULTS Our model of nurse practitioner–physician comanagement has 3 ele-
ments: effective communication; mutual respect and trust; and clinical alignment/
shared philosophy of care. Interviews indicated that successful comanagement
can alleviate individual workload, prevent burnout, improve patient care quality,
and lead to increased patient access to care. Legal and organizational barriers,
however, inhibit the ability of nurse practitioners to practice autonomously or
with equal care management resources as primary care physicians.

CONCLUSIONS Future research should focus on developing instruments to mea-
sure and further assess nurse practitioner–physician comanagement in the pri-
mary care practice setting.

Ann Fam Med 2018;16:250-256. https://doi.org/10.1370/afm.2230.

INTRODUCTION

W
ith imminent staffing shortages in the health care profession
and an increase in the volume of patients seeking primary care
services, patient loads are increasing rapidly, thus making it dif-

ficult for a single primary care professional to manage all patient care needs
effectively and efficiently.1-4 Therefore, policy makers are calling for new
primary care delivery models to meet the increased demands for care, espe-
cially due to patients with multiple comorbidities requiring more complex
primary care visits. Different models of care delivery have been proposed,
including team-based care, yet these models often have variability in task
allocation and professional roles.5 Identifying innovative models of care
delivery is increasingly important to meet these demands in primary care.

One proposed care delivery model includes having more than 1 pri-
mary care professional comanaging the same patient and sharing the work-
load responsibilities or care management tasks. Researchers have explored
comanagement of patients by 2 physicians in primary care,6 and by a phy-
sician and a nonphysician health care professional, such as a pharmacist.7,8

Allison A. Norful, RN, PhD,
ANP-BC1,2

Krystyna de Jacq, MSN, MPhil,
PHMNP-BC1

Richard Carlino, MD, FAAFP3

Lusine Poghosyan, RN, MPH, PhD,
FAAN1

1Columbia University School of ,
New York, New York

2Columbia University Medical Center
Irving Institute for Clinical and Transla-
tional Research, New York, New York

3Mosholu Medical Group, Bronx, New York

Conflicts of interest: authors report none.

CORRESPONDING AUTHOR

Allison A. Norful, RN, PhD, ANP-BC
Columbia University School of
Columbia University Medical Center Irving
Institute for Clinical and Translational
Research
630 W. 168th St, Mail Code 6
New York, NY 10032
[email protected]

Downloaded from the Annals of Family Medicine Web site at www.annfammed.org.
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No model, however, clearly describes the comanage-
ment relationship between physicians and advanced
practice nurses, such as nurse practitioners.

Nurse practitioners are registered nurses with
advanced master’s or doctoral degrees whose scope of
practice usually includes diagnosis and implementa-
tion of a patient care plan; regulations regarding the
scope of practice vary considerably among the states
regarding the need for physician involvement to treat
and prescribe.9 Policy makers, and the public, have
supported the expansion of nurse practitioners into
primary care,10 yet the comanagement relationship
between nurse practitioners and physicians remains
poorly defined. As more nurse practitioners are des-
ignated as primary care clinicians and practice inde-
pendent of physician oversight, a closer look at what
defines successful nurse practitioner–physician coman-
agement is warranted. The purpose of this article is to
present a theoretical model of nurse practitioner–
physician comanagement in primary care.

Definition of Comanagement
We define “comanagement” as 2 primary care profes-
sionals (a nurse practitioner and a physician) jointly
sharing the responsibility of all tasks needed to man-
age the health care of the same patient. These tasks
may include patient visits, such as for acute illness or
chronic disease management; pharmacologic manage-
ment, such as medication refills; diagnostic testing;
patient education, in terms of disease prevention or risk
reduction; and patient follow-up, such as interpretation
of laboratory values and making external patient refer-
rals based on test results. Comanagement also includes
sharing the administrative workload related to care
coordination, completing paperwork such as disability
or employment documents, and responding to patient
or caregiver phone calls.

History of Comanagement Model in Health Care
One of the first studies to examine comanagement
in health care was a large retrospective cohort study
about orthopedic surgery.11 This study examined
the effects of a surgeon and primary care physician
comanaging the same patient, and results showed posi-
tive associations between comanagement and shorter
hospital stays and fewer inpatient deaths. Further,
comanagement has increasingly become a common
practice across acute care organizations, and coman-
agement agreements have been implemented between
surgeons and other health care professionals.12 These
agreements clearly lay out responsibilities of each
party, communication methods and frequency, and
specific guidelines on resolution of disagreements. In
the outpatient setting, researchers have focused mainly

on comanagement by specialists and primary care phy-
sicians, or by pharmacists and physicians.7,13,14 These
studies showed that comanagement yields optimal clin-
ical outcomes, such as achieving blood pressure con-
trol. No published literature, however, has assessed the
effects of nurse practitioner–physician comanagement.

Similar Terms
Terms such as teamwork and collaboration are often used
interchangeably with comanagement. “Teamwork,”
however, is defined as a group of people working inter-
dependently to achieve a common goal9 and “collabora-
tion” is defined as 2 clinicians consulting with each other
and working concurrently by sharing knowledge and
expertise to achieve optimal patient care.15 Evidence is
clear about the benefits of team-based and collaborative
care,16 yet researchers have concluded that evidence is
lacking about comanagement approaches to care.17

Team-based care and collaborative care with nurse
practitioners often involve a hierarchy with team
members aligned in a vertical organizational struc-
ture based on profession or role. Vertical hierarchy
in an organization influences decision making and
subsequently may impede communication or increase
mistrust among team members from various profes-
sions.18 In contrast, comanagement involves a horizon-
tal organizational structure. Clinicians may comanage
across teams in a manner similar to a primary care
physician and a cardiologist comanaging the same
patient. These 2 physicians work within their own
teams within their practices, but overlap horizontally
to comanage the same patient. Within the same team,
an independent nurse practitioner may comanage the
same patient with a physician, in the same practice,
based on the urgency or complexity of a patient’s
needs. While research has found evidence of the
attributes of teamwork, including honesty, discipline,
creativity, humility, and curiosity,19 the literature fails
to capture the attributes of comanagement between
nurse practitioners and physicians.

METHODS
We built our model from the collective findings of 3
studies. First, using Walker and Avant’s method for
conceptual analysis,20 we conducted a literature search
in 5 electronic databases (Ovid Medline, CINAHL,
PubMed, Cochrane Review, and EMBASE) using the
following key words: comanagement; primary care;
nurse practitioner OR advanced practice nurse. A
total of 156 studies were reviewed. We extracted
information about nurse practitioner–physician
comanagement antecedents, relationships, defin-
ing attributes, and consequences. Next, using the

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PRISMA framework,21 a system-
atic review was conducted to
determine the effects of nurse
practitioner–physician comanage-
ment and found an increase in
primary care clinician adherence
to recommended care guidelines
and improved clinical patient
outcomes.22 Third, we performed
in-person qualitative interviews
with nurse practitioners and physi-
cians to obtain their perspectives on nurse practitio-
ner–physician comanagement including the willing-
ness of primary care professionals to comanage care,
descriptions of the dimensions of comanagement,
and how nurse practitioner–physician comanagement
affects patient care. Twenty-six interviews were con-
ducted until data saturation was reached and no new
information was emerging from the interviews.22,23
Results of all 3 studies were triangulated to build the
conceptual nurse practitioner–physician comanage-
ment model.

Theoretical Underpinnings
Our approach to investigating nurse practitioner–phy-
sician comanagement was guided by the theoretical
underpinnings of Donabedian’s quality of care model24
(Figure 1). This model provided us with a frame-
work to evaluate the quality of comanagement. Two
researchers met weekly to discuss the findings from
the 3 studies and extract information about each of
the 3 dimensions of quality of care (structure, process,
and outcome). First, the researchers obtained informa-
tion about comanagement structure, which involved
the organizational and clinician resources or policies
that needed to be in place for nurse practitioners and
physicians to comanage the same primary care patient.
Next, we evaluated process, that is, how comanagement
was being practiced, what interactions were necessary,
and the interprofessional relationships between nurse
practitioners and physicians. Finally, we evaluated
outcomes, which included the results of our systematic
review and the reported perspectives of the primary
care professionals in our qualitative study.

RESULTS
Antecedents of Nurse Practitioner–Physician
Comanagement
The primary antecedent for effective nurse
practitioner–physician comanagement is nurse practi-
tioner autonomy. Various policy bodies regulate nurse
practitioner scope of practice and nurse practitioner
licensure, leading to a wide variablity.9 In addition

to national or state-based legislation that defines the
nurse practitioner scope of practice, nurse practitioner
responsibilities are often determined by organizational
policy.25 Despite the adoption of laws that allow nurse
practitioners to practice independently of physician
oversight, organizational or facility policy may inhibit
and restrict a nurse practitioner–physician comanage-
ment model. These restrictions are especially salient in
the primary care clinics that adopt a physician-led hier-
archical infrastructure in which the physician has the
final decision-making authority. In this case, the nurse
practitioners do not comanage the patient care but
exercise a limited role. Further, organizational climate,
and the culture of organizations, heavily influenced by
organizational management, often do not identify and/
or do not accept nurse practitioners as primary care
clinicians.26 In this situation, the organization does not
provide the same resources to nurse practitioners as
they do physicians.27 These resources include support
staff, such as medical assistant help, enough examina-
tion rooms for patient visits, involvement on decision-
making committees, and availability of learning oppor-
tunities.23,28 Our model focused specifically on coman-
agement in which nurse practitioners and physicians
were viewed equally as primary care clinicians, shared
equal responsibility for primary care patient manage-
ment, and were provided with equal resources.

Vital Attributes
Effective nurse practitioner–physician comanagement
has 3 vital attributes: (1) effective communication; (2)
mutual respect and trust; and (3) clinical alignment,
also known as a shared philosophy of care (Figure 2).

Effective Communication
Effective communication is a 2-way process in which
primary care professionals send a message that is easily
understood by the receiving party to prevent misunder-
standing and to save time. Comanagement communica-
tion is essential for developing the patient care plan,
managing a change in patient health status, individual-
izing patient goals, and delineating each primary care
clinician’s role in the care plan as part of coordinating

Figure 1. Theoretical Donabedian quality of care underpinnings.

• Nurse practitioners

• Physicians

• Primary care

What are the necessary
attributes of effective

comanagement?

How is comanagement
carried out?

What takes place within
the nurse practitioner–
physician interaction?

What are the implica-
tions of nurse prac-
titioner–physician
comanagement?

OutcomeProcessStructure

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patient care.29 When the nurse practitioner and physi-
cian who are comanaging a patient do not have direct
contact with each during their daily activities, the
use of secure messaging through an electronic health
record (EHR) or telephone calls are the most frequent
form of communication.23 Some EHR systems, however,
have been found to inhibit communication because
the nurse practitioner and physician documentation is
located in separate locations within the patient chart,
thus preventing them from seeing each other’s notes.23
The setting size and space often influence the type
of communication used, with smaller settings using
more informal modes of communication, such as text
messages.30 Comanagement communication must be
performed in a timely manner that is dependent on the
patient needs, such as a change in patient acuity level.
The communication needs to be reciprocal with equal
sharing of ideas, new patient information, and feedback
necessary to improve quality of care.31

Mutual Respect and Trust
Respect and trust among nurse practitioners and physi-
cians is the second critical element of comanagement.
This attribute increases over time as physicians and
nurse practitioners work together longer32; develop-
ing reciprocal trust and respect of each other’s role in
care delivery can take up to 6 months.30 By gaining
trust, physicians are less likely to feel that they need
to supervise or “double-check” the work of the nurse
practitioner, thereby reducing redundancy of docu-
mentation and diagnostic testing.

Traditionally, some physicians view nurse practi-
tioners as having an inferior role in primary care. This
viewpoint inhibits nurse practitioners from working to
their full potential and can create mistrust or resent-
ment. The physician must have an understanding of
the education, training, and scope of practice for nurse
practitioners to build trust during allocation of tasks
and responsibilities.25 The optimal combination of

Figure 2. Nurse practitioner–physician comanagement.

Nurse Practitioner–Physician Comanagement Attributes

Nurse practitioner autonomy (practice free from physician oversight)

Organizational policy enables comanagement care delivery

Antecedents

Power sharing

Shared responsibility of patient care

Ability to meet demand of patient care

Decreased individual provider workload

Increased continuity of care for patients

Increased patient access to care

Consequences

Method to resolve con� icting opinions

Clinical alignment

Similar work ethic

Mutual goals for patient care

Agreement on rationale for care plan

Knowledge of each other’s care
management expertise

Mutual respect of disciplines

Trust of each other’s care decisions

Recognition of each other’s contri-
butions to patient care

Timely exchange

Full access to each other’s patient care documentation

Organizational communication modes support comanagement

Mutual medical language

Shared
Philosophy

of Care

Effective
Communication

Respect
and Trust

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nurse practitioners’ and physicians’ knowledge, culture,
and disciplines has the potential to positively contrib-
ute to the quality of patient care.

Shared Philosophy of Care
Physicians and nurse practitioners that we interviewed
agreed that each primary care professional must have
complementary practice styles that are congruent to
mutual goals for patient care, such as a shared philoso-
phy or having a clinical alignment in their patient care
plan.31 This shared philosophy includes approaches to
care management. Variability of approaches challenges
nurse practitioner–physician comanagement. For
example, one clinician may opt to treat mental illness
in primary care while the other clinician prefers refer-
ral to a specialist. Other examples include when to pre-
scribe an antibiotic or when to discontinue a patient-
specific treatment, such as pain management.

In the event of disagreement between primary care
clinicians regarding care decisions, discussion is vital.
However, a mutually agreed-upon protocol for conflict
resolution must be in place ahead of time to determine
who makes the final care management decision. This
protocol may vary by organizational policy or practice
setting. Clinical alignment also involves a similar work
ethic, such as time management styles. Without a simi-
lar work ethic, the workload may become unbalanced
and weighted toward 1 of the clinicians, potentially
leading to clinician burnout and increased strain. One
of the primary care professionals having a higher vol-
ume of daily patients than the other clinician may lead
to resentment, which may threaten mutual respect and
trust or communication, with the potential of indi-
rectly affecting patient care.

Consequences of Comanagement
At the level of the primary care professional, the pres-
ence of all 3 attributes of the model leads to clinician
cohesion. The stronger comanagement is, the greater
the potential for beneficial patient, clinician, and prac-
tice outcomes.22 One finding of our interviews was
that effective nurse practitioner–physician comanage-
ment alleviated individual clinician workload and the
strain to complete all recommended clinical care and
administrative tasks singlehandedly. A reduction of
primary care professional workload subsequently pre-
vents clinician strain, burnout, and fatigue, especially
with increased patient complexity. Nurse practitioner–
physician comanagement also enables interdisciplinary
collaboration between nursing and medicine, and better
care results from combining the experience and exper-
tise of clinicians from each discipline. Interdisciplinary
collaboration also promotes morale among team mem-
bers and leads to effective and efficient outcomes.33,34

Nurse practitioner–physician comanagement was
also found to increase patient access to care and pro-
mote continuity of care because patients have 2 clini-
cians familiar with their history and care needs.29,35
Longevity of patient and primary care professional
interactions is often described as a core value of high-
quality primary care.36,37 Further, fewer restrictions on
the scope of practice for nurse practitioners is associ-
ated with an increase in the number of nurse practi-
tioners practicing in rural or medically underserved
populations.38 Nurse practitioner–physician comanage-
ment in rural or medically underserved populations
allows primary care physicians to free time up for addi-
tional appointments, as well as provide patients with
more one-on-one time during patient visits to address
individual patients’ needs.3

DISCUSSION
More nurse practitioners are practicing as independent
primary care professionals, and developing innova-
tive approaches to integrate nurse practitioners and
physicians within and across team-based care models is
important. This article presents a theoretical model of
nurse practitioner–physician comanagement, including
the vital attributes of effective communication, mutual
respect and trust, and shared philosophy of care.

This novel theoretical understanding has several
potential uses. First, use of this model can help cre-
ate organizational policies needed to ensure the suc-
cess of nurse practitioner–physician comanagement.
When administrators, clinicians, and policy makers
promote effective comanagement, individual clinician
workload is reduced, thus preventing clinician strain,
burnout, and fatigue, especially with increased patient
complexity.23 Use of this model also enables increased
collaboration among clinicians who discuss and coordi-
nate the complex needs of patients, thereby providing
higher quality of care.34,39 Effective nurse practitio-
ner–physician comanagement also has the potential to
increase access to care because patients have 2 primary
care professionals familiar with their needs and plan of
care, thus promoting a continuity of care. If 1 clinician
is unavailable, the other can see the patient, preventing
a gap in access to care. By sharing the workload, nurse
practitioner–physician comanagement can lead to time
for additional appointments and/or more one-on-one
individualized attention to patient needs. We recom-
mend efforts toward interdisciplinary education within
academic institutions so that nurse practitioners and
physicians gain knowledge of each other’s disciplines
early on and learn strategies to comanage patient care
given the complexities of primary care delivery and the
identified strengths of each discipline.

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Attention to individualized patient care is espe-
cially important as reimbursement mechanisms shift
from volume-based to value-based care and provider
payments are reliant on achieving targeted quality
outcomes.40,41 The combination of nurse practitioner
and physician expertise in comanagement can help
to ensure the highest quality of care. Several studies
included in our systematic review demonstrated a sig-
nificant difference in guideline adherence in favor of
nurse practitioners and physicians comanagement of the
same patient.22 Furthermore, evidence shows that nurse
practitioners in primary care professional roles have
equivalent or superior patient outcomes and are poten-
tially cost saving.42 This finding suggests the potential
of nurse practitioner–physician comanagement to be
more cost effective than 2 physicians comanaging care.
More cost-effective studies about nurse practitioner–
physician comanagement are warranted.

Lastly, despite the increasing numbers of nurse
practitioners and physicians who are already coman-
aging in practice, a substantial gap in the literature
remains about how organizations should design
comanagement models. More evidence is needed
about which care delivery models are the most effi-
cient and effective in primary care. Nurse practitio-
ner–physician comanagement demonstrates promise
to alleviate some of the primary care strain, but more
research is needed to produce empirical and gener-
alizable evidence about its impact on clinical, cost,
and organizational outcomes. Our theoretical model
provides health services researchers with knowledge
to operationalize nurse practitioner–physician coman-
agement in future studies.

A survey instrument is currently being developed
from this theoretical model and tested psychometri-
cally to enable measurement of nurse practitioner–
physician comanagement in practice and research
settings. This survey instrument, once validated, will
provide primary care physicians, practice managers,
policy makers, and researchers the ability to further
investigate nurse practitioner–physician comanage-
ment and its impact on patient or practice outcomes.

The 3 vital attributes from our nurse practitioner–
physician comanagement model—effective com-
munication, mutual respect and trust, and a shared
philosophy of care—cannot exist without the presence
of legal and organizational policies that recognize
nurse practitioners as autonomous primary care clini-
cians. Further, effective nurse practitioner–physician
comanagement requires adequate organizational
resources and the willingness of nurse practitioners
and physicians to comanage. Opposing opinions about
the autonomy of nurse practitioners and the drive for
physician-led hierarchical infrastructures have pre-

vented autonomous practice of nurse practitioners in
primary care.43 As long as such limitations exist, the
effective comanagement care model cannot be fully
investigated or implemented. We recommend empirical
measurement of nurse practitioner–physician coman-
agement for future research.

To read or post commentaries in response to this article, see it
online at http://www.AnnFamMed.org/content/16/3/250.

Key words: primary care; nurse practitioner; comanagement; theory

Submitted July 5, 2017; submitted, revised, November 1, 2017;
accepted November 30, 2017.

Funding support: This study was supported by the National Institute of
Research (T32 NR014205) and the National Center for Advanc-
ing Translational Sciences, National Institutes of Health (TL1TR001875).

Disclaimer: The content is solely the responsibility of the authors and
does not necessarily represent the official views of the NIH.

Previous presentations: This paper was presented at the Academy
Health Annual Research Meeting; June 25-27, 2017; New Orleans, Loui-
siana, and the 2016 Eastern Nurses Research Society Annual Meeting;
April 13-15, 2016; Pittsburgh, Pennsylvania.

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