State of the State: Rules & Regulations for the APRN November 4 th, 2014 Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON Senior Director Advanced Practice Nursing Nursing Institute
Topics Cleveland Clinic s APRN s & current structure Regulatory Model for APRN s National landscape of APRN s Full Practice Authority Best practice models Future trends
How far we have come 1 st NP program in 1965 - Developed by a nurse & physician Currently 192,000 in the U.S. Ohio by the numbers- 11,473-6,725 Nurse Practitioners - 354 Certified Midwives - 2,767 Certified Registered Nurse Anesthetists - 1,627 Clinical Nurse Specialists
Cleveland Clinic APRN s Support all 4 roles: - CNM - CNP - CNS - CRNA 900 in total across CCHS APN Manager & Coordinator Roles
APRN s by the Numbers
The Million Dollar Question: WHY APRN s? Improved Access Cost Effective Provider Focus on the whole patient - Wellness - Prevention - Education Enhanced Revenue Continuity of Care
Managing Value Population Based Care Health Today: The FFS model Tomorrow: The Value-Based model Care of the individual Payment for any service we provide Predictability! Care of a population Payment based on our quality and efficiency performance Uncertainty and risk! 17
Concepts driving APRN Trends Increase need for primary care Increase need in outpatient care centers Increase need for rural & underserved areas Increase demand for academia
Economics of Using APRN s Quality care High patient satisfaction Cost-effective care delivery
National Landscape for APRN s
By the Numbers. Nationally over 150,000 NP s Over 50% of APRN s work in primary care Every day 11,000 more seniors become eligible for Medicare From 2016 on 23-25 million people will purchase coverage Predicting a shortage of 66,000 primary care physicians
APRN Regulatory Model
So what does this model really mean???? The states that have adopted the consensus model language; the practice is the same in all!
IOM Future of Nursing Report Comparison of costs, quality outcomes and access associated with a range of primary care delivery models. Examination of the impact of expanding the range of providers allowed to perform initial hospital admitting assessments. Capture of intended and unintended consequences of alternative reimbursement mechanisms for APRNs. Capture of the impact of health insurance exchanges on the role of APRNs in the provision of primary care in the U.S.
APRN s should be able to practice to the full extent of their education and training. Capture of intended and unintended consequences of alternative reimbursement mechanisms for Advanced Practice Nurses. Capture of the impact of health insurance exchanges on the role of Advanced Practice Nurses in the provision of primary care in the U.S.
Federal Policy Priorities Provide Opportunity for NPs to be full participants in the Insurance Exchange (Marketplace) Program. Enable NPs Patients to be Beneficiaries in Medicare Shared Savings Accountable Care Organizations (ACOs) Amend Medicare Conditions of Participation to Require Hospitals to Consider NPs for Appointment to Medical Staffs.
Federal Policy Priorities Pass the Home Health Care Planning Improvement Act (H.R. 2504/S. 1332) Authorize NPs to Document Evaluations for Durable Medical Equipment (DME) (H.R. 3833) Pass the Ensuring Access to Primary Care for Women and Children Act (S. 2694) Authorize NPs to Certify Medicare Patients for Hospice Care
Full Legal Autonomy for APRN s What? - Independent practitioners - Still practice in collaboration with other clinicians Where? - 19 states currently grant full authority Why? - ACCESS When? - 6 additional states have legislation in the pipeline How? - Research the economics of full practice - Support the cause
Go! Caution! Stop!
National Governors Associtation
NGA s Report Reviewed the literature surrounding APRN practice Reviewed the state rules & regulations surrounding APRN practice CONCLUSION: NPs are well qualified to deliver certain elements of primary care. States might consider changing scope of practice restrictions & assuring adequate reimbursement for services.
Legislative Updates
OBN Updates Joint statement: Nursing, Medicine & Pharmacy (09/2014) - Prescription of Naloxone to High- Risk Individuals Hydrocodone Combination Products (HCPs) Classified as Schedule II Controlled Substances (10/6/2014) Assuming ARPN as title
Signed into Law APRN s & PA s can admit in the state of Ohio (5/19/14) APRNS may now supervise certified hyperbaric technologists (9/4/14) ALL PRESCRIBERS of Opioids and Benzodiazepines must check OAARS before prescribing with limited exceptions (9/16/14) Consent for Minors who are prescribed Opioids (9/17/14)
Moving HB-301- To authorize a person not otherwise authorized to do so to administer certain drugs pursuant to delegation by an advanced practice registered nurse who holds a certificate to prescribe. - AKA: Can delegate medication administration to MA s! Combining 301 & 412 (PA bill) and help them get the bill passed in the lame duck session
APRN Cost Effective Practice Models
Hospitalist-based Teams Used in community hospitals to support Private Practice Physicians - Revenue generating services Used in newborn nursery/general pediatric units Used in surgical units for medical management - Decreased LOS, readmissions, managing comorbidities
Data to Show! 7.00 6.00 5.00 4.00 3.00 2.00 ALOS Linear (ALOS) 1.00 0.00 2013 2014 ALOS 6.18 4.844
APRN Led Clinics Express Care Health spots Chronic disease management - Extensive patient education (BILLABLE) Data to support ROI on billing is higher for APRN s/pa s versus physicians
Long Term Care Facilities Utilization of APRN s in nursing homes, LTAC s to manage patients One provider covers multiple sites Hospitalist model for LTAC Clinic appointment model for Nursing homes Billing independently
ED/CDU Led Teams Level 4-5 acuity patients triaged to this team upon presentation to ED All triaging; assessment in triage, order necessary studies 2-3 APRN s/pa s >28% of daily ED volume (55,000 / year)
APRN s at the Bedside Reduction in CLABSI Identification of Present on Admission Pressure Ulcers Fall prevention & reduction in falls with injury Compliance with Core measures Attention to readmissions Increase in specialty based certified nurses (CCRN, MSRN, CPN)
School Based Health Centers Serve students of underserved areas Communities with health care disparities Results in: - Increased physical activity - Healthy food choices - Decrease ED visits
How do we improve the State?
Professional Advancement Council/Committee participation Professional Organization involvement Nursing Research Presenting best practices Publishing
Opportunities Outcome measurement Education of all providers and administrative personnel - re: scope and utilization Ensuring APRN s are practicing to their full scope Provide full clinical support of all providers Involving the APRN in quality initiatives
Policy Involvement Get involved - Join an organization! It s okay to just belong Advocate for the role Front line involvement Educate our consumers Sit at the table!
Our Response We need strong action across political and professional lines in order to move toward an efficient and effective health care system We need to tell the world what we do!
Why APRN s? Improved Access Cost Effective Provider Focus on the whole patient - Wellness - Prevention - Education Enhanced Revenue Continuity of Care
STEEP: To deliver Safe, Timely, Effective, Efficient, Equitable, Patient-centered care
QUESTIONS Meredith Lahl, MSN, PCNS-BC, PPCNP-BC, CPON lahlm@ccf.org 216-445-2439