Julianne Nemes Walsh, MS, PNP-BC NAPNAP Spring Symposium April, 2013

1. State of the State: Nurse Practitioner Practice in Massachusetts Julianne Nemes Walsh, MS, PNP-BCNAPNAP Spring SymposiumApril, 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 Nursing2010 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

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 practicsewith regulation by own profession

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 2009Three 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 Ethics2001 • 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 theBoardof 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 $4.2-8.4 Billion in savings costs in next 10 years for Massachusetts

23. August 2012Massachusetts • 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. SB 1079 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

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 ConsensusRESOURCE https://www.ncsbn.org/2276.htm

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:http://www.malegislature.gov/Bills/Search

36. Call to Duty

37. Resources IOM REPORT: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx APRN Consensus Talking Points:https://www.ncsbn.org/2010_APRN_TalkingPoints_web.pdf APRN Legislative Handbook: https://www.ncsbn.org/2010_APRN_HandbookforLegislators_web.pdf 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 1990-2008: 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, 202-624-5395