1. Collaborating with Advance Practice Nursing
T. Benton, MD -The Children’s Hospital of Philadelphia

2. Advanced Practice Nursing @CHOP
APRNs – 460 (CRNP, CRNA, CNM, CNS)
APPs – 500 (PA,CRNP, CRNA, CNM)
Certified Nurse Practitioners - 406
Certified Nurse Midwife - 7
Certified Registered Nurse Anesthetist - 25
Clinical Nurse Specialist – 22
Physicians Assistants - 40
APRNs- 475 (CRNP, CRNA, CNM, CNS)
Advanced Practice Providers- 490 (PA, CRNP, CRNA, CNM)
Demographics:
Nurse Practitioners-424
Nurse Anesthetists –23
Nurse Midwives -7
Clinical Nurse Specialists-21
Physician Assistants -36

3. Nurse Practitioner- Physician Collaboration Requirements by State
Map Legend
NP Full Practice Authority
Collaboration for Controlled Substances
Collaboration for first two years
NP Supervisory Practice
NP Collaborative Practice
Source: This map combines Map1 “Overview of Diagnosing and treating aspects of NP practice,” and Map 2 “Overview of Prescribing aspects of NP Practice,” developed by Linda Pearson, The Pearson Report, Map was prepared for the Center to Champion Nursing in America.
© AARP All rights reserved

4. Current Practice Model
Collaborative Practice: NP is educated and licensed to practice in expanded role Performs acts of medical diagnosis and treatment Performs role in collaboration with and under the direction of a physician
Collaboration is an ongoing process by which an advanced practice nurse and a physician engage in practice consistent with agreed upon parameters of their practices

5. Collaborating Physician Expectations
Collaborating physicians are physician colleagues who establish a supervisory/collaborative relationship with a nurse practioner that is implemented according to state guidelines. However, they do not practice under a physicians license

6. Collaborating Physician
Varies by state, but many require collaborative agreements between MD and PNP, which are essential to the safety and quality of NP practice
MD can be of any discipline as a collaborator in most states
Family physician could be collaborator for a MH PNP
Level of independence of PNP’s vary by state, and institutions may set additional expectations
CHOP: All new patient visits require collaborating physician be present for key aspects of the evaluation.
Works well only when all team members are clear about expectations

7. PNP’s
Prescriptive authority for PNP’s issued by state under their license with their own NPI and license number, and DEA when appropriate
PNP’s should are not permitted to prescribe controlled substances under MD license in most states
PNP’s carry their own professional liability insurance independent of physician malpractice.
In cases of litigation, each individual will be held to the scope and standards within their practice discipline and according to the guidelines set forth by their state licensure, certifying boards and collaborative agreement tenets

8. NP Scope of Practice Education Licensure Scope
Minimum of a masters degree in nursing. Many NPs have a doctorate degree. All NPs are educated in an age group (neonatal NP; pediatric primary, acute or critical care NP; family NP, adult care NP, mental health – need to check your individual area with regards to specialized education requirements)
Licensure
NPs have a RN, NP and Prescriptive Authority license. NP license is not linked to the physician’s license. All NPs have national certification in the area of education/subspecialty
Scope
Certified Registered Nurse Practitioner (CRNP)—A registered nurse licensed in an advanced practice role who is certified by the Boards in a particular clinical specialty area and who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with and under the direction of a physician licensed to practice medicine in this Commonwealth. (PA State Board of Nursing).
Physician must be available in person, via phone or pager, for consultation or questions
Both NP and physician are accountable for the care of the patient

9. Expertise of Non-MD providers
Nurse Practioner
Nurse Anesthetist
Optometrist
Psychologists
Length of Graduate Education
2-4 years
2-3 years
4 years
4-6 years
Years of Residency/Fellowship
3-7 years NA
Not required
1 year
Total patient care hours required through training
hours
1 year clinical rotations

10. Psychiatric Mental Health NP Training
BSN(Bachelor’s of Science in Nursing) and RN state licensure
College/University based educational program
Credentials: MSN(Masters of Science in Nursing) with specialization in mental health *(not all specialize in MH; can be peds/fam practice)
Certification by American Nursing Credentialing Center(ANCC)
Passing certification examination post training
Credential obtained-PMH-NP-BC(psychiatric mental health nurse practioner board certified)
Recertification occurs at specified intervals for maintenance

11. CHOP MH NP fellowship program
Identified need to expand access to treatment and to lower costs
Explored practice models successful in other practice settings
Benchmarked with other academic psychiatry departments and community practices utilizing PNP’s for mental health care delivery
Partnered with PNP leadership at CHOP to develop clinical training program specific to our patient populations, identify highly qualified candidates, and to develop and implement a one year program that would enable to trainees to meet PNP specific requirements while developing needed expertise for our general and specialty programs

12. Training
Determined Scope of training for consistency with existing hospital guidelines:
Assessment and diagnosis including comprehensive health history, physical examination, interpretation of screening and lab tests, ordering and interpreting common diagnostic procedures, assessment and diagnosis of children and adolescents with uncomplicated mental health conditions including depression, anxiety, ADHD, ODD that fall within the expertise and knowledge base of the NP
Formulate a family centered health plan

13. Training Intervention
Treatment of children with uncomplicated mental health conditions including depression, anxiety, ADHD, autism
Prescribe medications for MH conditions guided by departmental policies
Provide patient/family education about treatments including purpose, regimens, interactions and side effects
Provide other appropriate interventions within the parameters, expertise and knowledge of the NP
Provide appropriate follow up care, consult with physicians and other health care providers and identify resources and referrals for problems beyond the scope of practice
Advocate for patients and families

14. Training
In addition to scope, PNP’s will have supervised clinical training with collaborating and supervising attending's in specialty programs for mood and anxiety disorders, psychopharmacology, eating disorders, substance abuse programs, ADHD programs, Autism/Dev Disabilities, neuropsychiatry, forensics, consultation-liaison and emergency psychiatry, neurology, child development, inpatient psychiatry, community mental health and preschool/school aged assessment and treatment

15. CHOP Training Model
Supervision: All new patients seen by attending physician to establish diagnosis and treatment plans
NP’s see pts. in subsequent visits as an “incident to” provider for established patients. Attending always on site.
NP’s consult as needed with attending if there are
Changes in the patients condition warranting a change in treatment plan
If patients care requirements are outside of scope
NP fellows attended didactics with fellows, grand rounds, and seminars
NP fellows were required to present locally and nationally to other PNP’s about pediatric mental health treatment and about models of training and collaboration for mental health PNP’s
All have gone on to do further specialty clinical training i.e. FBT for eating disorders, CBT for substance use treatment, etc.

16. CHOP training Model Funding:
1 PNP fellow per year at total cost of 100,000.00/year with agreement that they must remain with our program for 2 years
Generated modest revenue under the attending physician supervision model
First 3 years were donor funded; Program now to proposed for integration into University of Pennsylvania School of Nursing NP program in Mental Health
Benefits: Training and retention of highly qualified work force with skills specific to our clinical needs
Establishment of trust between providers with development of collegial well functioning care teams for key programs targeted for expansion, specifically autism/developmental disabilities, eating disorders and substance abuse.
Expanded access by assuming care of lower acuity patients and working side by side with physician collaborator for more complex patients or within subspecialty clinics

17. Satisfaction with collaboration
Physician satisfaction has been high with partnerships established by training program
PNP satisfaction has been high due to sense of collaboration and adequate support for remaining within scope or consultation for complexity
Patient satisfaction with access to providers, especially PNP’s

18. Billing
Goal: To develop an organizational structure of NP practice that will:
Improve access and throughput
Target high volume, low acuity patients
Match the right provider for the right patient
Allow appropriate PNP autonomy in a reimbursable manner
Provide cost effective use of personnel

19. Billing
Collaboration with physicians remains a core tenet of NP practice at CHOP
“Incident To”
Site of service: physician office setting (cannot use for inpatient care)
Billing: Under collaborating physicians provider number, reimbursed at 100% of physicians fee schedule rate
Services: Performed by NP, with collaboration/consultation with MD if needed
MD must be physically present in office suite when patient is seen
MD must perform the initial visit and develop plan of care and follow ups must be seen at defined intervals to reflect active participation in patient management(policy can be established by practice)
No co-signature is required if MD did not see the patient

20. Billing Shared/Split Service
Site of service: Hospital inpatient, hospital outpatient or emergency dept. setting
Billing: under MD provider number
Services: Performed by both NP and MD with bill considering contributions of both and can occur at distinct times of day
MD must provide some portion of face to face with patient to bill

21. Billing Direct Billing by Nurse Practioner site of service: any
services performed by NP
Billing: under NP provider number
Reimbursement: varying rates negotiated by payer; Some
payers do not reimburse PNP’s
NP salary cannot be on the Medicare cost report
Physician must be involved in care of all hospitalized patients

22. Billing Models Payers Aetna, Americhoice
Payer allows practices to bill under group number for NP services at contracted rates
IBC: consideration for credentialing and enrolling NP’s for direct billing rates
Currently piloting proposed NP billing model:
Outpt: NP has separate panel of patients consistent with scope
New patients will be seen with MD
Follow up patients will be seen by NP with MD consultation if new problem
is identified or family request
Billing incident to under MD, unless direct billing is indicated
Inpt: NP evaluates and manages a cohort that falls within their scope
Shared billing services if MD is involved

23. PNP Practice: Challenges
Patients must see NP as a provider, and not a less qualified practioner
Change in work flow for MD/PNP
Consistent standards of training and practice for PNP’s in MH
Payers-not all reimburse for PNP’s
Salaries relatively high ranging from 80, ,000 in underserved areas
collaborating MD arrangements allow a variety of PNP’s without MH training or expertise to collaborate with MD’s who do not have MH expertise

24. Challenges Payers Not all reimburse PNP’s for mental health services
MH PNP’s are second highest paid group of PNP providers and fewer in number than those in family practice or other areas
Consistency of practice; collaborating MD’s can be physicians who are not mental health experts; PNP’s prescribing psychotropic medications are not required to MH PNP’s in every state
Challenges to collaborating physician agreements in many states currently with some states not requiring collaboration

25. Opportunities
Expanded access for low acuity, high volume patients who can be managed by PNP
Skill set that is often more comforting for families as advocacy skills are strong
Reduce duplication of care services among teams thus decreasing costs, and allowing the right level of care by the right provider
Greater satisfaction for collaborative teams when right care can be given by the right level of provider, allowing each clinician to work to the full scope of their practice

26. References
Fairman JA, Rowe JW et al. Broadening of the Scope of Nursing. N Engl J Med. 2011; 3543
APRN model act/rules and regulations. Chicago: National council of State Boards of Nursing 2008: (
Finkel E. The Scope of Practice Debate. Pennsylvania Physician. 2015;2
National Council of State Board of Nursing.