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OBJECTIVES• Where have we come from? Why? y• Where are we now?• Where are we going?• Optimizing our future….
Where have we come from?1960s• First NP program established at the University of Colorado.• First education program for NPs working in northern p g g nursing stations began at Dalhousie University.• Canada’s health care system was experiencing: – changing role of the nurse from generalist to specialist; – a physician shortage (ratio 740:1) especially in rural areas;; – trend towards specialization in medicine, fewer MDs in primary care; and – emphasis on the curative aspects of medicine. History slides source: NPAO website; Jane Sanders (2010)
Where have we come from?1970s• Boudreau Report recommends expanded role of the RN and first university program in Ontario to prepare expanded role RNs.• First university based program to prepare expanded role RNs.• NPAO established as an affiliated Interest Group of the RNAO. O• CNA/CMA Joint Committee releases joint policy statement on the role of the NP.• Ontario Council of Health releases The Nurse Practitioner in Primary Care. History slides source: NPAO website; Jane Sanders (2010)
Where have we come from?1980s• First round of NP initiative falters.• NP education program closes at McMaster University.• NPAO continues to actively lobby to re-establish educational programs in Ontario.• Development of first ACNP Program "Expanded Role Program, Nurse" program – Neonatology.• CNS-NP role implemented in Level 3 NICUs following p g reduction in number of pediatric residents. History slides source: NPAO website; Jane Sanders (2010)
Where have we come from?1990s• HPRAC releases 8 recommendations in support of legislative authority for PHCNPs.• Bill 127, the Expanded Nursing Services for Patients Act is proclaimed.• NPAO expands its mandate to include all nurse practitioners.• Teaching hospitals express interest in ACNP role. History slides source: NPAO website; Jane Sanders (2010)
Where have we come from?1990s• Government announce a new Nurse Practitioner Initiative to improve access to PHC.• Council of Ontario University Programs in Nursing (COUPN) consortium develops the new PHCNP Program.• Post-Masters ACNP certificate programs Toronto and London.• College of Nurses of Ontario (CNO) approves the Extended Class registration. History slides source: NPAO website; Jane Sanders (2010)
Where have we come from?2000’s• Approvals for Nurse Practitioner led clinics.• HPRAC - Bill 179 – expanding mandate for NPs.• Regulation 965 – PHA - lobbying on admit, transfer, discharge elements.• Removal of MAC oversight on NP NP. History slides source: NPAO website; Jane Sanders (2010)
Where are we now?• We have grown from 1001 NPs (PHC) in 2008 to 1694 (1262 PHC, 133 P di t i 307 adult) i O t i PHC Pediatric, d lt) in Ontario.• Approvals for 26 NP led clinics.• Integration in all sectors; legislative barriers p g g partially y removed.• Since 1974, 28 RCTs have consistently shown that nurse practitioners are effective, safe practitioners and can positively influence patient, provider and health- f system outcomes.• While there has been a steady increase in the supply of family doctors and nurse practitioners ,there is still only f il d t d titi th i till l one nurse practitioner for every 10 family physicians in the province. History slides source: NPAO website; Jane Sanders (2010); CHSRF mythbusters, 2009
Where are we now?• Canadians are highly satisfied with care p g y provided byy nurse practitioners. A 2009 Harris/Decima poll of 1,000 Canadians found that: – one i fi h b in five has been t t d b a nurse practitioner; treated by titi – majority would like to see the role expanded; – greater than three in four would be comfortable seeing one in lieu of their family doctor; and – four in five feel that expanding their roles would be an effective way of managing healthcare costs. (Source: CHSRF mythbusters, 2009)
Where are we now?HPRAC – Bill 179• Royal assent in December 2009, awaiting regulations.• Removal of historic barriers – e.g. broader range of drugs and forms of energy.• Regulation 965 under the Public Hospital Act currently limiting scope and potential system impact transfer of impact, patients.• Advocacy to enable RN(EC)s to provide health services to hospitalized in-patients (without directives). (Source: NPAO, 2010)
Cost of health care• Today, health sector spending accounts for about 46 y, p g cents of every program dollar. If left unchecked, cost drivers could push health care spending to 70 cents of every program dollar in 12 years Health sector expense years. is projected to increase by $6 billion from 2009-10 to 2012-13. Source of health expenditures slides: MOHLTC Ontario website (2010)
Per-Capita Health Spending by Age Group, 2007Per-Capita Provincial Government Health Spending, by Age Group,Ontario, 2007, Current DollarsAge Spending Per Share of Population, Share ofGroup Person ($)1 2007 Population, 2030 Actual (Per Cent) Projection (Per Cent)<1 9,188.0 1.1 1.11–41 4 1,292.6 1 292 6 4.4 44 4.3 435–14 1,047.6 12.0 11.215–44 1,706.3 42.8 37.345–64 2,823.6 26.5 24.265+ 10,330.7 13.2 21.965–7465 74 6,883.1 6 883 1 6.9 69 11.7 11 775–84 11,843.7 4.7 7.485+ 20,702.4 1.6 2.8Total 3,127.0 100.0 100.01Weighted average. Sources: Canadian Institute for Health Information, StatisticsCanada and Ontario Ministry of Finance population projections (Fall 2009).
Demographic shift• Currently, 13 percent of the population is 65 years of age or older. By 2016, there will be six million seniors in y , Canada, composing 16 percent of the population. In Ontario, there are now approximately 1.5 million seniors, representing 40 p p g percent of Canadas seniors. That number is expected to double by 2028 (Ontario Seniors Secretariat, 2003).• The demographic profile of Ontario is one of an aging society. In 2009, 6.5 percent of Ontarians were over the age of 75 years, up from 4.6 percent in 1991. Projections indicate that in twenty years 10 6 percent of the years, 10.6 population will be over 75 years old. The total dependency ratio (the ratio of the population aged 0-19 and 65+ to the population aged 20-64) will be up to 79 279.2 percent. MOHLTC Ontario (2010)
Demographic shift• Dramatic increases in the number of seniors living in long-term care institutions. 38 percent of women and 24 l t i tit ti t f d percent of men 85 years and older live in an institution.• For many seniors, home care is the preferred method of receiving care. O i f i i One in four people placed i LTC could l l d in ld potentially be cared for in alternative settings.• 90 percent of older seniors living in long-term care institutions suffer from a mental disorder. In Ontario 88 disorder Ontario, percent of these institutions receive only five hours or less of psychiatric services per month for the entire resident population. population• Shortly after entering an LTC home, one in six residents receives a new antipsychotic drug that he or she was not taking before, and one in four receives a new drug for anxiety or sleep. Quality Monitor OHQC (2010)
Wait times• Wait times for an LTC bed are too long — an average of 105 days, or more than th d th three months. F people waiting th For l iti while at home, the wait time is 173 days (almost half a year). Wait times have tripled since the spring of 2005.• F il i di id l who cannot go h Frail individuals h t home t i ll spend 53 typically d days in hospital waiting for placement. As a result, currently 16% of all hospital beds in Ontario are occupied by patients designated as ALC who do not ALC, need to be in hospital.• In 2009 25% of patients spent more time in the ED receiving care than the recommended target The target. majority of patients did not get to see a physician within the timeframe recommended by national experts. About 6% of them left the emergency department before being seen. Quality Monitor OHQC (2010)
Primary care• About 7.1% (730,000) of Ontarians continue not to have a f il d t Ab t h lf of th family doctor; About half f these i di id l are individuals actively looking but can’t find one.• For people who already have a family doctor, only half can see th i d t th same or next day when sick. their doctor the td h i k• Compared to 10 other countries, Ontario and Canada have the worst record on timely access to primary care. Almost nine in 10 O Ontarians say they are waiting too long to see their doctor, and this indicator has gotten worse in the last three years.• I the last six years, the per capita supply of family In th l t i th it l f f il doctors has increased by 6.2%, and that of nurse practitioners by 82%. Quality Monitor OHQC (2010)
Health promotion• Half of Ontarians are not getting enough exercise, one in six are smoking and one in five are heavy drinkers.• Breastfeeding rates are increasing and teen pregnancy rates are decreasing, but there is still room to improve.• One-quarter of the p p q population does not g necessary get y health prevention services (e.g., pap tests, mammography and flu shots).• •People with low incomes or poor education are at higher i k f h lth behaviors and not getting h lth hi h risk of unhealthy b h i d t tti health prevention services.• Only 13% of Ontario doctors routinely provide patients with a li t of medications t k ith list f di ti taken, with 46% never ith providing a list.• About one in five seniors aged 65 and over are on a medication with potentially dangerous side effects effects. Quality Monitor OHQC (2010)
Chronic disease management• While complications from diabetes have decreased significantly over the past five years, patients are still not getting the regular monitoring of their condition and risk factors that they need.• Only half of patients with diabetes have their eyes and feet examined and slightly fewer than half are getting the medication they needneed.• The number of patients who die within one year of having a heart attack has improved slightly to one in 11, but b t we can still d b tt till do better. Quality Monitor OHQC (2010)
Quality - ECFAA• On June 8, 2010, the Excellent Care for All Act, 2010 (ECFAA) received Royal Assent Beginning with hospitals the Act requires Assent. hospitals, health care organizations to: – Develop and post annual quality improvement plans. – Implement p p patient and employee satisfaction surveys and a p y y patient relations process. – Link executive compensation to achievement of quality plan performance improvement targets. – Develop declarations of values after public consultation consultation. – Create quality committees to report to each hospital board on quality related issues. – Related amendments to Regulation 965 under the Public g Hospitals Act (PHA) were made and filed to support ECFAA.• The MAC would no longer be required to make recommendations to the board under s.7(2)(a)(v) of Regulation 965 under the PHA that relate to the quality of care provided by extended class nurses who are hospital employees. Quality Monitor OHQC (2010)
Where are we going?RNAO calls for:• Implementation of campaign commitment for funding for 25 additional NP-led clinics.• Implementation of funding for 150 new Nurse.• Practitioner (NP) Primary Health Care positions across health centres, family health teams, emergency departments, departments and other outpatient settings settings.• The removal of legislative and regulatory barriers to enable RN(EC)s to practice to their full scope.• Dedicated funding to enhance the management of chronic disease in Ontario. RNAO (2010)
Optimizing our future• Appropriate numbers and utilization of NPs; funding pp p g streams for the positions.• Removal of legislative barriers.• Examine and respond actively the drivers for inclusion of NP roles in primary and institutional settings.• Demonstrate value in enhancing access, quality, equity, appropriateness and cost effectiveness. i t d t ff ti• Stay true to patient need and system focus and don’t lose “nursing” component of the role. g