Transcript MICHIGAN ’S SCOPE OF PRACTICE FOR APRNs - MI -CNS

MICHIGAN’S PUBLIC
HEALTH CODE & SCOPE
OF PRACTICE FOR APRNs
A TIME FOR CHANGE
History of Michigan’s Regulation
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Michigan’s Public Health Code (PHC) was written
in 1978 and reflected a very new role at the time.
The current PHC is out of date, difficult to interpret,
and is often misinterpreted.
After 25 years it is time to update the Code and
regulatory model!
There is a newly published national guideline and
model for APRN regulation.
Michigan needs to develop regulatory language
consistent with these new national guidelines.
Basis for Regulation of Scope of Practice
Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations, 2007
Interdisciplinary report on scope of practice regulation:
(State Boards of Medicine, Nursing, Occupational Therapy, Pharmacy, Physical
Therapy & Social Work)
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Consumer/Patient safety is primary
Professional interests too often trump reasoned decisions based
on evidence
Health care education and practice have developed over years so
that professions share some skills or procedures with other
professions.
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No longer reasonable to expect completely unique scope of practice for
each healthcare discipline
Scope of practice changes should reflect the evolution of each discipline
After all, the scope of medicine is very different than it was 3 decades
ago, just as it is with nursing/APRNs
Assumptions Related to Scope of Practice
Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations (2007)
Public protection (the purpose of regulation) should have top
priority in Scope of Practice (SOP) decisions, not professional
self interest.
 Changes in SOP are inherent in our current healthcare system
 Collaboration between all healthcare providers should be the
professional norm
 Overlap among professions is unavoidable and necessary
 Practice acts should require licensees to demonstrate that they
have the requisite training and competence to provide a service
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Basis for Decisions
Related to Changes in SOP
 Established
history of the scope of practice within the
profession
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APRNs have a strong record and history
 Education
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and training
There are now consistent standardized competencies for
CNPs, CNMs, and CNSs,
 Supportive
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evidence
40 years of consistent, strong evidence of quality care by
APRNs
 Appropriate
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regulatory environment
Consensus model that links licensure, accreditation,
certification and education brings this into alignment
Michigan’s Current Environment for APRN
Scope of Practice:
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Michigan severely restricts patient choice: Grade F
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MI ranks 44th out of the 50 states
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Lugo, N.R., O’Grady, E.T., Hodnicki, D.R., Hanson, C.M. (2007). Ranking state NP
regulation: Practice environment and consumer healthcare choice. The American
Journal For Nurse Practitioners 11(4):8-9,15-18, 23-24.
MI restricts Nurse Practitioner autonomy: Grade F
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As of 2009, 31 states reported some degree of an expanded
legislative or regulatory NP SOP
23 states have no requirement for Physician Involvement
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Pearson, L.J. (2010). The Pearson Report. A National overview of nurse practitioner
legislation and healthcare issues. The American Journal for Nurse Practitioners.
14(2), 49—53.
2010 Pearson Report
Pearson, L. J. The Pearson Report 2010, The American Journal for Nurse Practitioners, Vol. 14; No. 2, February
2010. www.webnponline.com.
Physician Involvement in Diagnosis
Physician Involvement in Prescription
2010
2010
Required No Written
Documentation
Written Documentation
Written Documentation
2010
2010
None
None
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Meeting Primary Care Needs: Nurse
Practitioners an Untapped Resource
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Increased need for access to primary care with health
care reform
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Shortage of primary care providers
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Currently 150,000+ nurse practitioners (NP)
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66% (close to 90,000) in primary care
Meeting Primary Care Needs: Nurse
Practitioners an Untapped Resource
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20% practicing in rural areas
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About 8,000 NP new graduates per year, with 7,000
prepared as primary care providers
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Substantial evidence over 40 years that NPs provide
quality, cost efficient care
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NPs well positioned to be part of the solution to
issues of access to care
Barriers to Practice for Nurse
Practitioners
Pohl, JM, Hanson, C, Newland, J., Cronenwett, L. (2010) Unleashing nurse practitioners’ full the potential to address
primary care needs of the nation. Health Affairs, 29, pp
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Wide variation across states in terms of licensure
laws and payor policies
Where restrictive, this limits access to a group of
cost-effective, high quality primary care providers
Where physician supervision is required, cost is
increased
No evidence that restrictive regulations protect
consumers/patients
Difficult to educate for effective primary care teams
when laws/policies vary
CNS’s: Impact Access, Quality &
Safety Across the Care Continuum
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CNS in practice since the 1940’s.
Three major clinical practice areas;
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Manage care of complex & vulnerable populations
Educate and support interdisciplinary staff
Facilitate change and innovation within health care systems
CNS services in primary care or home settings
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Prenatal services
Transitional care from hospital or rehabilitation facilities to home
Psycho-educational self-care counseling and coaching to manage
chronic disease
Gerontological services
Palliative care
Chronic wound management
CNS’s: Impact Access, Quality &
Safety Across the Care Continuum
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Clinical and financial outcomes
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Preventing readmissions by effectively managing
discharge planning and home care for the elderly.
Reducing the cost of chronic illness in patients with heart
failure, asthma, chronic pulmonary disease, and epilepsy
through effective community programs and promotion of
self-care. (Newman, M. (2002). A specialist nurse intervention reduced hospital readmissions in patients with
chronic heart failure. Evidence-Based Nursing, 5(2), 55-56, DeJong, S. (2004) The effectiveness of CNS-led community-based
COPD screening and intervention program. Clinical Nurse Specialist, 18(2) 72-79
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Wellness and preventive care programs to identify
individuals in the work place at risk for disease resulting
in a reduction in health care cost and insurance premiums.
( Nancy Dayhoff, Clinical Solutions, LLC)
Certified Nurse-Midwives CNMs:
Advocates for the Health Care of Women
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CNMs are educated to provide comprehensive primary
health care to women including normal obstetric and
gynecologic care.
CNMs attend 6% of all births in Michigan
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(10% nationally).
Studies have repeatedly and effectively demonstrated
the high quality of the Midwifery model of care.
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More face-to-face time with clients
Emphasis on education, prevention and health-promotion
Increased satisfaction with care:
Customer satisfaction => Compliance with care => Optimized
health => Efficient utilization of health-care dollars
Certified Nurse-Midwives: Advocates
for the Health Care of Women
Proven Cost-Effectiveness:
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Decreased resource utilization
Shorter hospital stays
Lower rates of technological
intervention
Fewer Cesarean Sections
Fewer epidurals
Decreased maternal and fetal
complications.
Rosenblatt RA, et al. Interspecialty
differences in the obstetric care of lowrisk women. American Journal of Public
Health 1997;387:344-51.
Certified Nurse-Midwives: Advocates
for the Health Care of Women
“Obstetrical care in the United States is burdened by
soaring costs and a paradoxical inability to bring
rates of infant mortality in line with those of other
developed countries. A look at the costs and
outcomes of obstetrical care demonstrates that a
greater reliance on the use of certified nursemidwives (CNMs) could help solve these problems.
Midwifery has a good track record with regard o
quality of care; it represents a good value for health
care dollars, and it rates high in client satisfaction.”
Gabay and Wolfe, 1997
Updating the Michigan Health Code
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Is based on strong evidence of a need for change
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Will bring licensure into alignment with national
recommendations for accreditation, certification, and
education, as well as with the majority of other states
FOUR Components of Regulation:
(LACE)
Licensure
Certification
Education
Accreditation
Regulation Needs to Support:
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The use of each provider to their full extent of
education and scope of practice
An expectation that collaboration is not
unidirectional, but holds each provider accountable
for care delivered under their own license
An expectation that all providers will be accountable
for outcomes of care
Foundational Requirements
for Licensure
(NCSBN Website)
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Boards of Nursing will:
License APRNs as independent practitioners with no
regulatory requirements for collaboration, direction or
supervision (this does not negate the professional ethic and
reality of collaboration by ALL health disciplines)
Have at least one APRN representative position on the board
and utilize an APRN advisory committee that includes
representatives of all four APRN roles
Institute a grandfathering clause that will exempt those
APRNs already practicing in the state from new eligibility
requirements
Consensus: The Time is Now
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is substantial data/evidence over 40 years
regarding quality care of APRNs.
 Many organizations concur that removal of SOP
barriers can improve primary care quality and
efficiency of care.
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PEW report
IOM (Crossing the Quality Chasm, 2001)
Macy Foundation
Rand Report (2009)
Proposed Changes to Michigan’s
Public Health Code Will:
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Promote increased access to health care
Reduce costs
Clarify regulation of APRNs
Proposed Changes to Michigan’s
Public Health Code Will:
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Improve Michigan’s ability to attract and
retain APRNs
Bring Michigan’s APRN regulations into
alignment with national standards
Provide for transparency of data on APRN
practice
 All APRNs will be practicing under their
own license as opposed to current system
which promotes confusion and invisibility
of actual APRN practice