NPAA Addressing the Health Care Crisis


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Presentation by Barbara Watts & Terry Watkins Fall 2010

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  • 2014 DNP ---75% of NPs in Family Practice
  • Clinical hours are one on one supervised one on one residency in different populations such as pediatrics womens health Family practice etc.
  • This development builds on the Registered nurses previous experience of assessing and treating patients.
  • Wouldn’t use the word limited, would probably use “specific to education” When speaking add that Renewal requires 1000 minimum practice hours, along with 24 h for the RN renewal and 6 hours of pharmacy CE
  • Service: add health management - expound on diagnostic tests “such as xray and blood test” Add “current” to scope of practice
  • Emphasis the research is country wide and from other disciplines and organizations as well as nursing research
  • Add the number of years we have had a shortage Add regarding RESTRICTIVE practice environment Add a third sub bullet and state the number of NPs in the state has not significantly grown over the past three years desspite graduation hundreds from the nursing schools in the state due to the attrition
  • May want to state collaborative practice is limited to the equivalent of 3 full time NPs per Physician and qualify that collaboration is required with only with only 10% of our patients.
  • Creating reimbursement issues and restraint of trade Chart audits are beneficial if the physician and NP are utilizing them to improve quality - (maybe just place 10% on site rule and then discuss it, wouldn’t want this to get taken out of context later
  • Discuss our training, undergraduate pharmacology and incorporated into every diagnosis State when bill passes, rules and regulations would require and additional course on current medication scheduled prescribing pit-falls and updates.
  • Explain Schedule 2 medications are specifically needed for pediatric patients (ADD) so they can pay attention and do well in school and for end of life medications for pain relief for terminally ill patients History includes 4 years of attempting to have legislators at the least hold a fair public hearing to look at these issues> These items were all reference in Dr. Bentley Task for report from 2004 which recommended increased of nurse practitioners to provide primary care to decrease chronic illness
  • WE ARE Not: Asking to be physicians Asking to practice without collaboration Asking for privileges we have not been trained and nationally certified in WE ARE Asking to remove restrictive barriers that prevent access to care, Asking to decrease the amount of time our patients are in pain Promoting wellness and addressing preventative care Certified, Educated and trained to provide primary care The patients of Alabama deserve access to care, the best care we can give
  • Chapter 420­1­5Healthto 5 p.m., Monday through Friday, official state holidays excluded.(2)Composition of the Board. The Medical Association of the State of Alabama is the State Board of Health. The Board functions through the State Committee of Public Health as constituted by Code of Ala. 1975, §22­2­4, which is composed of12 members of the Medical Association of the State of Alabama and the chairman of each of four councils provided for by statute. The 16 members function under the leadership of a chairman and a vice chairman elected by the membership for a term of four (4) years.
  • NPAA Addressing the Health Care Crisis

    1. 1. Nurse Practitioner Alliance of Alabama Addressing the Health Care Crisis
    2. 2. NP Education and Certification <ul><li>Entry into a NP graduate program requires a BSN degree and active RN license </li></ul><ul><li>NP programs offer either a Master’s or Doctorate of Nursing Practice (DNP mandatory in 2014) </li></ul><ul><li>Sub-specialties </li></ul><ul><ul><li>Adult NP </li></ul></ul><ul><ul><li>Family NP (75% of NPs) </li></ul></ul><ul><ul><li>Acute Care NP </li></ul></ul><ul><ul><li>Pediatric NP </li></ul></ul><ul><ul><li>Gerontology NP </li></ul></ul><ul><ul><li>Psychiatric & Mental Health NP </li></ul></ul>
    3. 3. NP Education and Certification <ul><li>Program curriculum </li></ul><ul><ul><li>2-3 years Master’s, additional 2-3 yrs DNP </li></ul></ul><ul><ul><li>National Standards </li></ul></ul><ul><ul><li>Specific to sub-specialty </li></ul></ul><ul><ul><li>All include advanced courses: </li></ul></ul><ul><ul><ul><li>Pharmacology </li></ul></ul></ul><ul><ul><ul><li>Pathophysiology </li></ul></ul></ul><ul><ul><ul><li>Physical Assessment, Diagnostics, and Health/disease Management </li></ul></ul></ul><ul><ul><ul><li>Clinical Hours (One on one supervised residency) </li></ul></ul></ul><ul><ul><ul><ul><li>Approximately 660 hrs/Masters + 550/DNP </li></ul></ul></ul></ul>
    4. 4. NP Education and Certification <ul><li>The emphasis in a graduate NP program is on the development of clinical and professional expertise necessary for comprehensive primary care </li></ul><ul><li>Builds on the RN’s previous experience of assessing and treating patients </li></ul>
    5. 5. NP Education and Certification <ul><li>National Certification (AANP or ANCC) </li></ul><ul><ul><li>Exam specific to sub-specialty </li></ul></ul><ul><ul><li>Certification to practice specific to sub-specialty </li></ul></ul><ul><ul><li>Certification mandatory for practice </li></ul></ul><ul><ul><li>Renewal every 5 years by exam or CEUs + practice hours </li></ul></ul>
    6. 6. Scope of Practice <ul><li>NPs are licensed independent practitioners who practice autonomously and in collaboration with health care professionals to assess, diagnose and treat acute and chronic diseases </li></ul><ul><li>Additional emphasis on health promotion and disease prevention </li></ul><ul><li>Services include: </li></ul><ul><ul><li>Health and illness management </li></ul></ul><ul><ul><li>Ordering and interpreting diagnostic tests </li></ul></ul><ul><ul><li>Prescribing pharmacologic and non-pharmacologic therapies </li></ul></ul><ul><ul><li>Teaching and counseling </li></ul></ul>
    7. 7. Alabama Health <ul><li>Ranked in top 5 states for hypertension, obesity, high cholesterol, and diabetes </li></ul><ul><li>Ranked 2 nd for strokes and heart attacks </li></ul><ul><li>Ranked 2 nd for preterm births </li></ul><ul><li>36%of Alabama’s children are obese </li></ul><ul><li>(America’s Health Ranking; United Health Foundation; 2009) (Kaiser Family Foundation;; 2007) </li></ul>
    8. 9. Quality of NP Practice <ul><li>45 years of research consistently demonstrates the high quality of NP care* </li></ul><ul><li>Numerous studies (from multiple disciplines) have shown no difference in primary care patient outcomes between NP and physician* </li></ul><ul><ul><li>Health status </li></ul></ul><ul><ul><li>Number of prescriptions written </li></ul></ul><ul><ul><li>Return visits </li></ul></ul><ul><ul><li>Referrals </li></ul></ul><ul><ul><li>Emphasis on Preventive Care </li></ul></ul><ul><ul><ul><ul><ul><li>*Resources available </li></ul></ul></ul></ul></ul>
    9. 10. Alabama Access to Health Care <ul><li>60 of the 67 counties in Alabama designated as health provider shortage area (Alabama Department of Public Health) </li></ul><ul><li>Alabama ranked 51 st in NP consumer choice regarding restrictive practice environment and regulation </li></ul><ul><ul><li>NP graduates of Alabama schools leaving state (data from UAB, UAH, & USA) </li></ul></ul><ul><ul><li>Incentive for NPs living near border states to work in those states (Ga, Ms, Tn) </li></ul></ul>
    10. 12. State Rules & Regulation <ul><li>Collaborative practice agreement with physician </li></ul><ul><li>Advance Practice and Joint Committee approval </li></ul><ul><ul><li>Three members appointed by BOM (only one of the three physicians must be in a collaborative practice with CRNP or CNM) </li></ul></ul><ul><ul><li>Three members appointed by BON (2 NPs, one CNM) </li></ul></ul>
    11. 13. Practice Restrictions in Alabama <ul><li>Lack of recognition of NPs as PCP in state law </li></ul><ul><ul><li>Creating reimbursement issues </li></ul></ul><ul><ul><li>Problems withorders for physical therapy, medical equipment, and home health visits </li></ul></ul><ul><li>Collaborative practice rules too restrictive </li></ul><ul><ul><li>Supervision vs Collaboration </li></ul></ul><ul><ul><li>In rural areas, 10% on site rule unrealistic </li></ul></ul>
    12. 14. Practice Restrictions in Alabama <ul><li>Limited Prescriptive Authority </li></ul><ul><li>Dual regulation </li></ul><ul><li>Primary Care Provider Designation </li></ul><ul><li>Direct reimbursement </li></ul><ul><li>Alabama and Florida only states that do not allow NPs to prescribe controlled substances </li></ul>
    13. 16. Controlled Substance Prescriptive Authority
    14. 17. Controlled Substance Prescribing <ul><li>Refers to substances controlled by the DEA </li></ul><ul><li>Schedules I-V </li></ul><ul><li>Schedule I: Illegals –not used in clinical practice (PCP, Heroin, Ectasy, LSD, etc) </li></ul><ul><li>Schedule II: includes pain meds (morphine, oxycodone) and meds used for ADHD (ritalin, adderall, vyvanse, concerta) </li></ul><ul><li>Schedule III: Hydrocodone (Lortab), Tussinex (cough meds) </li></ul><ul><li>Schedule IV: Anxiolytics and sleeping pills </li></ul><ul><li>Schedule V: Lomotil, Lyrica, Codeine Cough preparations </li></ul>
    15. 18. Controlled Substance Prescribing <ul><li>Are NPs qualified to prescribe? </li></ul><ul><li>YES </li></ul><ul><li>NPs in other states have safely been prescribing for years. We all have the appropriate pharmacologic training to do this. No state has ever reversed any prescribing privilege to NPs </li></ul>
    16. 19. Controlled Substance Prescribing <ul><li>How will this affect patient care? </li></ul><ul><ul><li>Increase efficiency and patient volume </li></ul></ul><ul><ul><ul><li>Coffey Study completed in Florida in (2009-2010) found that in a week approximately 4 hours per NP was wasted seeking physician signatures for controlled substances prescriptions (equals 12-16 pt visits/wk) </li></ul></ul></ul><ul><ul><li>Decrease treatment delays and avoid unnecessary pain and suffering </li></ul></ul><ul><ul><li>Assist treatment of patients with ADHD (drugs are schedule II—requires written script—cannot call in) </li></ul></ul><ul><ul><li>Examples are lomotil (diarrhea), cough suppressants & pain medications (pneumonia, bronchitis, injuries/fractures, and Concerta (ADHD) </li></ul></ul>
    17. 20. Controlled Substance Prescribing <ul><li>Prescriptive authority for NPs should be regulated by the ABON </li></ul><ul><ul><li>Professional boards should solely regulate their profession (supported by the American College of Physicians, AANP, and NCSBN) </li></ul></ul>
    18. 21. <ul><li>Nurse Practitioner Regulatory Authority </li></ul>   + ▲ ▲ ▲ + + ▲ States with Nurse Practitioner Regulations Controlled by Board of Nursing States with Nurse Practitioner Regulations Controlled by Board of Nursing and Board of Medicine States with Separate Advanced Practice Board Prescription Only Under Joint Authority of Board of Nursing and Board of Medicine State Education Department Source: State Nurse Practice Acts  American Academy of Nurse Practitioners, 2009
    19. 22. Legislative History <ul><li>NP’s Requested changes in the 2010 Legislative session </li></ul><ul><li>Schedules II – V prescribing </li></ul><ul><li>Prescriptive authority regulated by ABON </li></ul><ul><li>All Joint Committee members to be in collaborative practice </li></ul>
    20. 23. Clarification <ul><li>We are not : </li></ul><ul><ul><li>Asking to be physicians </li></ul></ul><ul><ul><li>Asking to practice without collaboration </li></ul></ul><ul><ul><li>Asking for privileges for which we are not trained and nationally certified </li></ul></ul><ul><li>We are : </li></ul><ul><ul><li>Asking to remove restrictive barriers to care </li></ul></ul><ul><ul><li>Asking to decrease the amount of time our patients remain in pain </li></ul></ul><ul><ul><li>Asking to promote wellness and preventative care </li></ul></ul>
    21. 24. Summary <ul><li>Preventing professionals from practicing to the full extent of their competence negatively affects health care costs, access and quality </li></ul>
    22. 25. ALABAMA LACK OF INSURANCE (18 th /11.9%)
    23. 26. ALABAMA CHILDREN IN POVERTY (47 th /27.3 %)
    24. 27. Alabama Department of Public Health 2009 2010 Medical Association of the State of Alabama 2010 Alabama Board Of Medical Examiners Jt.Comm Jt.Comm Jt.Comm