1. Julianne Nemes Walsh, MS, PNP-BC NAPNAP Spring Symposium April, 2013
State of the State:
Nurse Practitioner
Practice in Massachusetts
Julianne Nemes Walsh, MS, PNP-BC NAPNAP Spring Symposium April, 2013

2. Contemporizing Nursing Practice

3. 2008: Prior to IOM Report
Uniformity -to enable APRNs to practice to the full extent of their education and licensure
Ease of mobility across state lines
NCSBN APRN Advisory and APRN Work Groups collaborated to form APRN Consensus Model 2008

4. 2008
L A C E Model=Movement across State Lines
Goal is align interrelationships among Licensure, Accreditation, Certification, Education (LACE)
APRN Consensus Model-85 Nursing Organizations
Includes NAPNAP, ANA, AFPNP, AANP…support.

5. Institute of Medicine: Future of Nursing 2010 KEY MESSAGES
Nurses should practice to the full extent of their education and training
Nurses should achieve higher levels of education and training
Nurses 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

6. 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

7. 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
There is often debate about wording in the practice act that may require a supervision agreement but, in practice, our discriminator is the requirement of any written agreement of supervision
We value the independent role as having no such restrictions
Have seen abuse of the required collaboration

8. AANP 2013 Nurse Practitioner Practice Environment 1-29-13

9. 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
The AMA is making a strong argument for interprofessional collaboration in which they supervise both the PA and APRN. The Consensus Model is one of independent practice and independent prescriptive authority for the APRNs. The model is not one of required collaboration and this push back against APRN independence will be our greatest hill to climb.

10. 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

14. 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

15. 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

16. SB 1079 - HB 2009 Three Prong Approach
Nursing Practice will be regulated by Board of Nursing only
Removal of supervision of prescription writing
Removal of collaborative practice agreements

17. “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

18. Then Why Change Law? Improved access to care for all Americans
Increased consumer choice and value of care
Meet 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)

19. 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

20. ANA Nursing Code of Ethics 2001
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.

21. AANP/NAPNAP/ACNP/NONPF/NPWH
APRNs 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

22. 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
$ Billion in savings costs in next 10 years for Massachusetts
Reimburse the same amount for basic medical services, whether provided by a
physician, a PA, or an NP.

23. August 2012 Massachusetts
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

24. National Governors Council Review of Quality Care Components, December 2012
NPs 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

25. An Act Improving The Quality of Health Care and Reducing Costs
SB HB 2009
An Act Improving The Quality of Health Care and Reducing Costs

26. Current Status Joint Committee on Public Health
Collective job to explain why the bill is needed
Refute misinformation from opposition- Medicine
Bill will go either:
Favorable release
Amend with favorable release
Send to study
Oppose

27. All along this Process there will be opponents trying to kill the bill
Joint Commission on Public Health
Joint Committee on Health Care Financing
OR / and
Committees on Ways and Means
Senate or House Floors
Second and Third Readings
Enactment by one chamber then repeats in the other chamber

28. Who knows best what nurse practitioners do?

29. Writing A Letter/Calling
Name and number of the Bill
Who you are
Where you practice and location by street corner
Constituent who cares about what he/she is doing to represent you
Offer to have come see you practice
Keep the focus on patient and not profession

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

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

32. Silence is APATHY

33. Campaign for APRN Consensus RESOURCE

34. Educate peers, patients, legislators, family, colleagues
ready for dialogue/conversations
examples of care
“can and may” based on education and training not on state regulations
Educate yourself and others, quality of care, cost effectiveness, outcome data
NCSBN, APRN Toolkit
Support MCNP and lobbyists

35. Bill Search
mailto:

36. Call to Duty

37. Resources
IOM REPORT:
Change-Advancing-Health.aspx
APRN Consensus Talking Points:
APRN Legislative Handbook:
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 : 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,