MICHIGAN’S PUBLIC HEALTH CODE & SCOPE OF PRACTICE FOR APRNs

1. MICHIGAN’S PUBLIC HEALTH CODE & SCOPE OF PRACTICE FOR APRNs A TIME FOR CHANGE

2. History of Michigan’s Regulation • 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 • The current PHC is out of date, difficult to interpret, and is often misinterpreted.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.

3. Basis for Regulation of Scope of PracticeChanges 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) 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. 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

4. Assumptions Related to Scope of PracticeChanges 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

5. Basis for Decisions Related to Changes in SOP Established history of the scope of practice within the profession APRNs have a strong record and history Education and training There are now consistent standardized competencies for CNPs, CNMs, and CNSs, Supportive evidence 40 years of consistent, strong evidence of quality care by APRNs Appropriate regulatory environment Consensus model that links licensure, accreditation, certification and education brings this into alignment

6. Michigan’s Current Environment for APRN Scope of Practice: • Michigan severely restricts patient choice: Grade F • MI ranks 44th out of the 50 states • 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 • As of 2009, 31 states reported some degree of an expanded legislative or regulatory NP SOP • 23 states have no requirement for Physician Involvement • 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.

7. 2010 Pearson ReportPearson, 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

8. Meeting Primary Care Needs: Nurse Practitioners an Untapped Resource • Increased need for access to primary care with health care reform • Shortage of primary care providers • Currently 150,000+ nurse practitioners (NP) • 66% (close to 90,000) in primary care

9. Meeting Primary Care Needs: Nurse Practitioners an Untapped Resource • 20% practicing in rural areas • About 8,000 NP new graduates per year, with 7,000 prepared as primary care providers • Substantial evidence over 40 years that NPs provide quality, cost efficient care • NPs well positioned to be part of the solution to issues of access to care

10. Barriers to Practice for Nurse PractitionersPohl, 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 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

11. CNS’s: Impact Access, Quality & Safety Across the Care Continuum • CNS in practice since the 1940’s. • Three major clinical practice areas; • 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 • 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

12. CNS’s: Impact Access, Quality & Safety Across the Care Continuum • Clinical and financial outcomes • 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 • 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)

13. Certified Nurse-Midwives CNMs: Advocates for the Health Care of Women • 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 • (10% nationally). • Studies have repeatedly and effectively demonstrated the high quality of the Midwifery model of care. • 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

14. Certified Nurse-Midwives: Advocates for the Health Care of Women Proven Cost-Effectiveness: • 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 low-risk women. American Journal of Public Health 1997;387:344-51.

15. 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 nurse-midwives (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

16. Updating the Michigan Health Code • Is based on strong evidence of a need for change • Will bring licensure into alignment with national recommendations for accreditation, certification, and education, as well as with the majority of other states

17. FOUR Components of Regulation: (LACE) Certification Licensure Accreditation Education

18. Regulation Needs to Support: 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

19. Foundational Requirementsfor Licensure (NCSBN Website) • The 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

20. Consensus: The Time is Now • There 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. • PEW report • IOM (Crossing the Quality Chasm, 2001) • Macy Foundation • Rand Report (2009)

21. Proposed Changes to Michigan’s Public Health Code Will: • Promote increased access to health care • Reduce costs • Clarify regulation of APRNs

22. Proposed Changes to Michigan’s Public Health Code Will: • 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