3/3/2014. Advance Practice Nursing-a Varied and Unique Role in a Comprehensive Breast Program. Lecture/Session. Health Care Reform

Transcription

1 Advance Practice Nursing-a Varied and Unique Role in a Comprehensive Breast Program Colleen Johnson, R.N.N.P., CBPN IC Carondelet Health System Lecture/Session RT s #43 No Disclosures Health Care Reform Advanced practiced registered nurses (APRN s) have positioned themselves to serve an integral role in national health care reform. A successful transformation of the nation s health system will require utilization of all clinicians, particularly primary care providers, to the full extent of their education and scope of practice. APRN s are highly skilled to provide a range of services including care coordination, chronic care management, and wellness and preventive care. 1

2 Patient Protection and Affordable Care Act Millions of people have greater protection against losing or being denied health insurance coverage, and better access to primary and preventive services. APRN s will be called upon to meet the needs of these patients. Physician shortages within the United States continue to prove problematic Multi-faceted Roles of the APRN Educational Requirements Most states recognize the Clinical Nurse Specialist, Nurse Midwife, Nurse Practitioner and Nurse Anesthetist as APRN s. They are required to sit for a certification examination through a national nurse certification organization. Education and specific scope of practice vary from state to state. Most state s now require a Master s degree. 2

3 APRN s-staffing Benign Breast Disease Clinics Produces shorter wait for diagnoses at lower cost for women with benign breast conditions. Conditions such as cysts, fibrocystic breast, pain, and nipple discharge as well as breast cancer are evaluated initially by an advanced practice nurse. APRN s take the lead in diagnosing patients, working with on site equipment to obtain mammography, ultrasound and MRI examinations. Patients whose conditions cannot promptly be evaluated as benign are referred to surgeons for consultation Virginia Mason Medical Center Developed such a clinic in 2008 The average time from presentation to final diagnosis for patients with benign conditions dropped from 15.8 to 3.8 days 18 percent fewer surgical procedures were required 29 percent fewer imaging studies were performed Patient satisfaction among women with benign breast disease as well as breast cancer was at 98% the first year Patient Evaluation Patients received clinical and imaging evaluations including core biopsies before being seen by a breast surgeon. The efficiency of this model leads to cost savings for both payers and providers Higher quality care can be achieved at lower cost by rethinking standard clinical pathways. March 2013 Sharing Nursing s Knowledge 3

4 Clinical Breast Examination-An Art A correlative clinical breast examination should be done on any woman presenting for breast health screening. Detection of any dominant mass or abnormal feel or appearance of the breast is another early detection tool to ultimately reduce breast cancer deaths. Training/certification courses are available to enable participants to become proficient in the art of breast physical examination. Certification NCBC Clinical Breast Examination Certification Program was developed to promote consistent breast health throughout the nation. The program is designed to utilize a standard technique of Clinical Breast Examination Skills to accomplish CBE s paramount objective APRN s, R.N. s and Technologist s can sit for the certification Technologist s by standard of practice are certified for correlative CBE Reimbursement for CBE There is no reimbursement for performing a screening breast examination. APRN s can bill for problematic or high risk consultations including clinical breast examination. 4

5 APRN s as Part of the Interdisciplinary Team Specialty core teams include the role of the Breast Cancer Nurse (BCN). The APRN has the creative ability for protected time within the schedule which allows patients to return for diagnostic work ups quickly. Same day service may be possible. Improve information sharing among providers. Ability to advocate with authority to meet treatment goals of the patient. APRN s as Risk Assessment/Genetics Clinicians Development of the breast cancer education and risk assessment program Hands on clinician Genetics counselor Risk Assessment Identifying women who may be at higher then average risk should remain one of the most important clinical assessments we perform. Being able to potentially prevent a breast cancer is a powerful motive to do the very best job we can. Coupled with a thorough clinical breast examination and excellent breast imaging, finding cancer at it s earliest stage and even preventing it is now a reality. 5

6 Sporadic Breast Cancers-How Good Are We at Identifying Women? DNA and Clinical History More then 80% of women who develop breast cancer have little to no family history. Combining family and personal history, clinical history; risk assessment scores and DNA evaluation can help to identify approximately 30% more high risk women 3% more breast cancers. Clinical Risks and Genetic Markers Clinical Risk Profile Questions currently utilizes GAIL risk model Based on the GAIL score of 1.7% or greater five year risk or 20% or greater lifetime risk. Oral DNA swab is obtained to look for genetic markers Proven to upgrade 23% of patients with elevated GAIL risk to high risk status allowing for closer surveillance, MRI examinations and chemoprevention 6

7 Cancer Genetic Counseling The identification of genes that when mutated, are associated with cancer development has transformed cancer detection and cancer management. The genetic revolution has resulted in a shift from genetics (hereditary transmission) to genomics, which refers to the study of multiple genes. Genetic and genomic information can be used to describe the biology of disease, characterize malignancies, develop new therapeutic modalities, and identify individuals who are at risk of developing cancer Future Needs Further advances in the science of clinical cancer genetics and genomics will increase the need for professional nurses trained in genetics and genomics and cancer care. Nurses who provide comprehensive cancer genetic risk counseling are often advanced practice oncology nurses with specialized education in cancer genetics and hereditary cancer predisposition syndromes. Collaborative relationships between healthcare providers and specialty organizations with a focus in genetics are essential to provide comprehensive care to high risk individuals. Varied Roles Cancer risk assessment and education Facilitation of genetic testing Pre and post test counseling and follow up Provision of personally tailored cancer risk management options and recommendations Psychosocial counseling and support services Practice is consistent with guidelines defined by an individuals state nurse practice act, the nurses education, the scope of the nurses role, and standards of oncology nursing practice. 7

8 Vital Link Advanced practice nurses are a vital link in the assessment of women at high risk for breast cancer, education, and appropriate referrals for management. Use of chemoprevention to prevent development of breast cancer among high risk women has been limited despite clinical evidence of it s benefit. Extensive education regarding risk/benefit and risk perception could greatly impact the likelihood of women agreeing to take preventative medication. Educational and training Opportunities Courses are available to receive training and receive a Certificate of Completion Certification is not required but very helpful in landing a position in the field Certified Genetics Nurse R.N. license plus five years experience as a genetics nurse. Successful passing certification examination through the Genetics Nursing Credentialing Commission Advanced Practice Nurse in Genetics (APNG) Master s or Doctorate plus 300 hours in genetic nursing Certificate of Attendance Courses Fox Chase Personalized Cancer Risk Assessment City of Hope 8

9 APRN s as Oncology Navigators Educational Preparation and Certification Over the past two decades, there has been an increase in nurses performing as navigators, evolution of the navigator role itself, and attempts to standardize the nurse navigator role all of which have shown a need for nurse navigators to have additional oncology experience and specialized education. There is no specific professional experience, degree, or certification which entitles a nurse to be classified as an oncology navigator Training Programs Breast Health Navigator Training Edu Care Harold P. Freeman Patient Navigation Institute 9

10 National Consortium of Breast Centers Certification CBPN (I) Certification in Imaging CBPN (C) Certification in Cancer CBPN (IC) Certification in Imaging and Cancer Experience An experienced oncology nurse possesses a comprehensive knowledge base of pathophysiology of cancer, treatment modalities, disease progression, and system management, which leads to improved outcomes. APRN Offers Comprehensive Care An APN navigator offers additional dimensions to program offerings, patient care, and symptom management. Adding the APN role can add components of research, clinical practice, education, consultation, and administration into the navigation position results in more comprehensive integration of medical and nursing perspectives. 10

11 APRN s and Research Having Advanced Practice Nurses mentor clinical nurses in the area of research and RFP protocols can yield many new national, regional and local research initiatives These initiatives can open doors for patients and families to explore possibilities to enhance medical outcomes and improve quality of life The Commission on Cancer requirement for potential research accruals is rising from 4% to 6% in Nursing research can play an instrumental role in increasing accruals. Clinical Trial Ideas??? Wellness nutrition and exercise Cognitive before, during and after chemotherapy Analysis of symptoms and lymphedema following breast cancer surgery 5 year follow up on newly diagnosed breast cancer patients Interventions for improving quality of life in breast cancer survivors 11

12 APRN s as Administrators Can serve as Director of Breast Health Services. Lead member of the BPL Oversight can include the Cancer Program. Cancer Committee Program development Operations Business and strategic planning Accreditation process APRN s Collaborative Practice Agreements 18 states and the District of Columbia allow APRN s to practice independently without physician involvement. 8 states require APRN s to collaborate with physicians only when prescribing medications. 24 states require APRN s to collaborate with physicians to diagnose and treat patients, and prescribe medication. 4 of these states (Connecticut, Indiana, Minnesota, and Pennsylvania) require a written collaborative practice agreement only to prescribe medication 12

13 Billing and Reimbursement The American Nurses Association has worked hard to ensure that APRN s receive direct reimbursement for services from Medicaid and working just as hard to see that coverage is expanded by Medicaid. APRN s across the U.S. have obtained a national provider Identifier that facilitates their electronic direct billings. By obtaining NPI s, APRN s can help give a more realistic picture of their billing and reimbursement making it easier to prove their value. Questions? 13