Julianne Nemes Walsh, MS, PNP-BCNAPNAP Spring SymposiumApril, 2013

State of the State: Nurse Practitioner Practice in Massachusetts

Contemporizing Nursing Practice

2008: Prior to IOM ReportUniformity -to enable APRNs to practice

to the full extent of their education and licensure

Ease of mobility across state linesNCSBN APRN Advisory and APRN Work

Groups collaborated to form APRN Consensus Model 2008

2008L A C E Model=Movement across State Lines

Goal is align interrelationships among Licensure, Accreditation, Certification, Education (LACE)

APRN Consensus Model-85 Nursing OrganizationsIncludes NAPNAP, ANA, AFPNP, AANP…support.

Institute of Medicine:Future of Nursing2010 KEY MESSAGESNurses should practice to the full extent of

their education and trainingNurses should achieve higher levels of

education and trainingNurses should be full partners, with

physicians and other health professionals in redesigning health care in the USA

Effective workforce planning and policy making require better data collection and an improved information infrastructure

IOM Recommendations Remove scope of practice barriers Expand opportunities for nurses to lead and manage collaborative

improvement efforts and diffuse successful practices Implement nurse residency programs Increase baccalaureate nursing proportions Double doctorate level nurses by 2020 Ensure that nurses engage in lifelong learning Prepare and enable nurses to lead change to advance health Build an infrastructure for the collection and analysis of

interprofessional healthcare workforce data

Practice Definitions Independent (Full) - no requirement for a written collaborative

agreement, no supervision, no conditions for practice

Collaborative (Reduced) - a written agreement exists which specifies scope of practice and medical acts allowed with or without a general supervision requirement by a MD, DO, DDS, podiatrist

Supervised (Restricted) - direct supervision required in the presence of a licensed, MD, DO, DDS, podiatrist with or without a written practice agreement

AANP 2013 Nurse Practitioner Practice Environment 1-29-13

NCSBN APRN Consensus Model

The Consensus Model supports independent practice and independent prescriptive authority for the APRNs.

The Consensus model is inter-professional collaboration amongst independent practitioners

Overlapping practicse with regulation by own profession

Expected Response

The model is not one of required collaboration

Push back against APRN independence will be our greatest hill to climb

American Medical Association-SOPP

Sponsors for H2009 Petitioners: Kay Khan, Paul Donato, Ellen Story,

Bradley H. Jones, Stephen Kulik, Bruce J. Ayers, Matthew A. Beaton, Paul Brodeur, William N. Brownsberger, Thomas J. Calter, Christine E. Canavan, Edward F. Coppinger, Marcos A. Devers, Stephen L. DiNatale, Benjamin B. Downing, James J. Dwyer, Sean Garballey, Denise C. Garlick, Anne M. Gobi, Thomas A. Golden, Kenneth I. Gordon, Bradford Hill, Jay R. Kaufman, Peter V. Kocot, David P. Linsky, Brian R. Mannal, James R. Miceli, Kevin J. Murphy, Alice H. Peisch, Denise Provost, Dennis A. Rosa, Tom Sannicandro, John W. Scibak, Carl M. Sciortino, Frank I. Smizik, Thomas M. Stanley, Aaron Vega, Daniel B. Winslow, Jonathan D. Zlotnik, Benjamin Swan, William S. Pignatelli, John H. Rogers, Paul McMurtry, Randy Hunt

Why are names of sponsors important to you as a NP?Recognize those legislators who are serving

you

Write them a letter, make a phone call to thank them

When you run into them at an event, note you appreciate their sponsorship and let them know your available to answer any questions

SB 1079 - HB 2009Three Prong Approach

Nursing Practice will be regulated by Board of Nursing only

Removal of supervision of prescription writing

Removal of collaborative practice agreements

“Change the Language and not the Care”Nurse practitioners will continue to refer when

necessary and refer to any specialist, whether a physician, respiratory therapist, behaviorist, or dentist in order to provide the best care for their patients

Nurse practitioners will continue to collaborate Nurse practitioners will continue to practice in

settings they are in now and be able to expand these settings

Nurse practitioners will not change the care yet arbitrary and artificial barriers to care will be removed

Then Why Change Law?Improved access to care for all AmericansIncreased consumer choice and value of

careMeet demands of chronic care with new

opportunities for advanced practice nurses to develop innovative practices for the chronically ill

Provides access to care for mental health services otherwise not available due to lack of providers

Improve the quality of health care services to population of 30 million in need of health care in the coming years (well documented for 50 yrs)

Benefits to Consumers if Remove Scope of Practice Barriers for APN

supervision and delegation requirements create administrative costs linked to APRNs, and these costs would be reduced under the Bill

greater choice among settings where health care is provided

stimulates competition thus driving costs down

ANA Nursing Code of Ethics2001 8.2 Responsibilities to the public

Nurses, individually and collectively, have a responsibility to be knowledgeable about the health status of the community and existing threats to health and safety. Through support of and participation in community organizations and groups, the nurse assists in efforts to educate the public, facilitates informed choice, identifies conditions and circumstances that contribute to illness, injury and disease, fosters healthy life styles, and participates in institutional and legislative efforts to promote health and meet national health objectives.

AANP/NAPNAP/ACNP/NONPF/NPWHAPRNs practice infinite variety of settings, ranging

from the intensive care unit of trauma centers to schools, patients’ homes, prisons, long-term care facilities, nursing homes, and private practices

Do not support creating statutory or regulatory requirements that link an individual clinician’s ability to obtain state licensure to the formation of care teams with other disciplines

THIS IMPEDES TRANSPARENCY, ACCOUNTABILITY, FLEXIBILITY, AND EFFICIENT USE OF INDIVIDUAL CLINICIAN MANPOWER

Reducing Costs: Improving Quality, RAND STUDY 2009 Allow NPs and PAs to practice independently,

without physician oversight. Allow greater practice autonomy for NPs by

eliminating the requirement that theBoard of Registration in Nursing consult and reach consensus with the Board of Registration in Medicine to promulgate its Advanced Practice Nursing regulations

Reimburse NPs and PAs directly for their services Allow consumers to designate a PA or NP as their

primary care provider

$4.2-8.4 Billion in savings costs in next 10 years for Massachusetts

August 2012Massachusetts• effective 11/5/2012 Chapter 224 of the Acts of 2012

• “providers not physicians” in language

• Global Payment System-Transparency

• Allows a nurse practitioner (NP) to sign, certify, stamp, verify, and endorse forms as well as provide affidavit that was previously required a physician to sign

• Shortfall of Chapter 224 of the Acts of 2012: Does not expand the scope of practice of NPs as recommended by IOM

National Governors Council Review of Quality Care Components, December 2012NPs were found to have equal or higher patient

satisfaction rates than physicians and also tended to spend more time with patients during clinical visits

NPs are better able to provide preventive education through the delivery of anticipatory guidance

Patient satisfaction found to be linked to quality of care

SB 1079 HB 2009

An Act Improving The Quality of Health Care and Reducing Costs

Current Status Joint Committee on Public HealthCollective job to explain why the bill is neededRefute misinformation from opposition- Medicine

Bill will go either: Favorable release Amend with favorable release Send to study Oppose

All along this Process there will be opponents trying to kill the bill

Joint Commission on Public Healt

h

Joint Committee on

Health Care

Financing

OR /

and

Committees on Ways and

Means

Senate or Hous

e Floor

s

Second and

Third Readings

Enactment by

one chamber then repeats in the other

chamber

Who knows best what nurse practitioners do?

Writing A Letter/CallingName and number of the BillWho you areWhere you practice and location by street

cornerConstituent who cares about what he/she is

doing to represent youOffer to have come see you practiceKeep the focus on patient and not profession

Joint Committee on Public Health- NOW 4-26-13

Joint Committee on Health Care Finance-HOPE by 7/13

Silence is APATHY

Campaign for APRN ConsensusRESOURCE

https://www.ncsbn.org/2276.htm

Educate peers, patients, legislators, family, colleagues

ready for dialogue/conversationsexamples of care “can and may” based on education and training not on state regulationsEducate yourself and others, quality of care, cost effectiveness, outcome dataNCSBN, APRN ToolkitSupport MCNP and lobbyists

Bill Search

mailto:http://www.malegislature.gov/Bills/Search

Call to Duty

ResourcesIOM REPORT: http

://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

APRN Consensus Talking Points:https://www.ncsbn.org/2010_APRN_TalkingPoints_web.pdf

APRN Legislative Handbook: https://www.ncsbn.org/2010_APRN_HandbookforLegislators_web.pdf

Bauer, J. Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners 22 (2010) 228–231

Newhouse, R. et al. Advance practice nurse outcomes 1990-2008: A systematic review, Nursing Economics, (2011), 29:5

Rand Corporation, Controlling health care spending in Massachusetts: An analysis. (2009).

Schiff M. National Governors Association, Health Division Report, 12/12/12. Center for Best Practices, 202-624-5395