Survival Tips for the Novice NP

1. Survival Tips for the Novice NP Katie de Leon-Demare NP, MN, FNP 2nd Annual NPAM Conference October 2, 2010

2. Challenges faced by Novice NPs New Role & Responsibilities: New Competencies Exception Drug Status Billing Referrals & Consultations Diagnostics Third Party Payors & Insurance Companies Liability/ Risk Management Unionization Avoiding Isolation

3. Challenges faced by Novice NPs (Cont’d) New Team: Who are your champions? Who needs to learn about the role? Who needs to be convinced? New Practice Environment: What are expectations of the NP? What are changes are needed to integrate NP?

4. Issues to consider in your first NP position(Szanton, S. et al, 2010, JAANP) Patient Factors Colleague Factors Clinic Factors Success requires intention !

5. Issues to consider in your first NP position(Szanton, S. et al, 2010, JAANP) Patient Factors Acuity level match with your comfort level? Available resources that impact your ability to provide care? What needs can be met with addition of an NP?

6. Issues to consider in your first NP position 2. Colleague factors: Learning Practice Styles Learning scopes of practice & overlap Mentorship Collaborative practice vs. supervision

7. Degrees of Collaboration

8. Issues to consider in your first NP position 3. Clinic Factors What is their past experience with NPs in provider mix? What are productivity expectations? Does mission of the clinic match with values of the NP? Scheduling: NPs different from MDs

9. Issues to consider in your first NP position 3. Clinic Factors Scheduling: NPs different from MDs Sick vs. well visits Follow-up vs. Rx refills Well vs. high-needs patients Procedures Balance and pace new intakes Adminstrative time

10. Issues to consider in your first NP position 3. Clinic Factors Front desk staff Rostering patients with the NP Educate staff of limits of your practice Prescribing limitations, forms, procedures Accurate & Consistent message when booking patients: “Care from the NP will not differ from that of the Doctor”

11. Issues to consider in your first NP position 3. Clinic Factors: Regular meetings with manager Monthly, 3 months, 6 months - annual Regular Clinic Rounds with the team Public relations: signs, pamphlets, stamp Network with NPs in the region

12. Making the transition from RN to NP Letting go Delegate nursing function/services Teach to maximize RN role within your setting The Strong Model

13. Strong Model of Advanced PracticeAckerman et al (1996). American J of Critical Care, 5: 68-73

14. Issues to consider in your first NP position Survivor Tools developed by the WRHA: NP Implementation ToolKit Orientation Guidelines NP Learning Needs Assessment www.wrha.mb.ca/professionals/nursing Look under advanced practice nursing workshop 2008

15. Overcoming Prescribing Stumbling Blocks Navigating EDS Exception Drug Status (EDS) -list of drugs approved as eligible benefits under Pharmacare Therapeutics Committee, MB Health Minister of Health gives final approval

16. Overcoming Prescribing Stumbling Blocks Navigating EDS Part 1 common products: aerochambers, test strips common antibiotics, OCPs, anti-hypertensives Part 2 drugs used when alternative tx not effective or not tolerated e.g. Azithromycin, Levoquin, Macrobid, Rx should include “ meets EDS criteria”

17. Overcoming Prescribing Stumbling Blocks Navigating EDS EDS Part 3 -drugs considered for reinbursement based on specific criteria & require request and approval PPIs, Celebrex etc, Actonel etc, Mirena, Lantus EDS: WPG (ph)788-6388 (Fax) 942-2030 Outside WPG: (ph) 1-800-557-4303 (Fax) 1-877-208-3588 Identify collaborating physician Once approved, NPs can refill prescription Appeals process through Therapeutics Committee

18. Overcoming Prescribing Stumbling Blocks Navigating EDS EDS Part 3 - Some products not covered: appetite suppressants, smoking cessation products, ED products, vaccines Options: Patients can pay out of pocket 3rd party insurance

19. Overcoming Prescribing Stumbling Blocks Navigating EDS EDS list is always changing and updated www.gov.mb.ca/health/mdbif

20. Overcoming Prescribing Stumbling Blocks Narcotics, Benzo’s, Controlled substances Some tips for efficiency & ease Meeting with collaborating MD & pt & you Set up schedule/contract for refills Advise front desk staff

21. Overcoming Prescribing Stumbling Blocks Practical Tips: Meet your community pharmacists Facsimile RX form template – available through CRNM Resources: RX files Drug Comparison Charts www.rxfiles.ca

22. Third Party Payors: We’re getting there Manitoba Employment & Income Assistance Medical Forms Worker’s Compensation Board MPIC (September 2010)

23. Third Party Payors: We’re getting there In progress: Discuss with case worker on case by case basis Insurance Companies (GWL) Not yet: Most federal government forms Revenue Canada Health Canada Dept of Veterans Affairs

24. Diagnostics: Avoiding Pitfalls Pulmonary Function Tests (also making progress) Stress Tests MRIs

25. Consultations & Referrals Consultation request opinion/advise Payable and auditable service Referral specialist takes over care Can only bill for the visit

26. Consultations & Referrals Work in progress Develop a roster of specialists who take consults from NPs If this is first time for specialist to receive NP consultation provide your billing number and information.

27. Tariff Codes Specific to RN Extended Practice 8110 -Health History Oral hx only 15 minute period 8141-Health  Promotion 15 minute period 8100 Communication initiated by pt/family telephone/email/fax 8101 Communication initiated by practitioner telephone/email/fax

28. Tariff Codes Specific to RN Extended Practice: Consultations 8107 - from allied health e.g. Counsellor?NP 8108 -to allied health e.g. NP ? O.T. 8139 -from family M.D. e.g. home care issues 8140 - NP ? NP e.g. NP in specialty practice

29. Tariff Codes Specific to RN Extended Practice 8109 Case management outside of office visits E.g. meeting with teacher, public trustee, home care case worker & family, Patient present

30. Tips on billing: RN Extended Practice Attach notations to procedures: site, number of lesions Attach notations on special situations: e.g. Pre-ops - Document procedure, surgeon & OR date

31. Tips on billing: RN Extended Practice Develop a list of common tariffs Remember you can have more than one tariff in a clinic visit Discuss unique RN EP codes with billing clerk Make your work count !!!

32. Liability Insurance Employer covers general vicarious liability insurance CRNM/CNA provides liability insurance for NPs ($5million) What is not covered: Disciplinary costs AON Reedhouse (CNPI)

33. Unionization Manitoba Nurses’ Union with your region or health facility MNU local 141 – WRHA community/ER NPs NP salary scale, Protected time, on-call, shift differential

34. Lessons learned NPs need champions & liaisons. Overlap of roles need to be clarified. Talk about liability. Policies & procedures need to be reviewed. An informed system promotes utilization and acceptance.