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Collaborating with Advance Practice Nursing

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Presentation on theme: "Collaborating with Advance Practice Nursing"— Presentation transcript:

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.


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