Post on 05-Feb-2016
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Nurses, Advanced Practice Nurses: Workforce for the
21st CenturyJulie Fairman, PhD, RN, FAAN
ProfessorRWJ Investigator in Health
PolicyDirector, Barbara Bates Center for the Study of the History of
Nursing
Health Reform Dilemmas
PaymentAccessQualityCostProvider Supply
Increasing specialization
Family practice, down 51 percent
Internal medicine, down 18 percent
Obstetrics-gynecology, down 16 percent
Pediatrics, down 8 percent General surgery, down 4
percent
Dermatology, up 7 percent Emergency medicine, up
18 percent Diagnostic radiology, up
34 percent Pathology, up 122 percent Anesthesiology, up 150
percent
Is your facility currently seeking physicians?
No: 14%
Yes: 86%
If yes, what type? (check all that apply)
Primary care . . . 81%
2007 Physician and Nurse Supply Survey,Council on Physician and Nurse Supply
Not Enough Primary care physicians
NY VNA, circa 1900, VNA Coll.
“nurses…particularly effective at improvisation, invention….”
Loretta Ford Collection
Innovative Experiments:
1965: Duke University PA Program
Charles HudsonThelma Ingles
Nurse
Doctor
Who shall provide care?????
Dietician, Social Worker, etc.
Who Should Provide Care:
Ms. Shade is a 56 year old woman with a 4 year history of Non-Insulin Dependent Diabetes Mellitus. She has a 10 year history of smoking more than 1 pack per day. She is on a fixed income due to a past disability related to arthritis, another chronic illness. Her current weight is about 25% over the recommended limit for her height, and she also suffers from high blood pressure. On her last visit to her health care provider, her blood pressure was 149/85, her fasting blood glucose level was above normal, around 140 mg/dl, and her hemoglobin A-1C, was elevated at 9 percent. Her feet were still in pretty good shape, warm with palpable pulses bilaterally, and showed no signs of the typical changes accompanying uncontrolled diabetes. At this visit Mrs. Shade requested and received information about a weight loss and low salt diet plan, an exercise plan that was appropriate for low income people, referral for county transportation resources, referral to a community-based “Quit Smoking” program, and correct use of a recently purchased glucometer and home blood pressure set.
Other healthprofessionals
NurseDoctor
NursesDoctors
Borderlands
ContextThe American healthcare system is fragmented and
difficult for many patients to navigate. The average Medicare patient sees seven different
doctors, according to the New England Journal of Medicine. Patients with multiple chronic conditions may see up to 16
physicians annually. It’s easy for important aspects of a patient’s medical
history or personal care preferences to fall through the cracks.
A lack of care coordination leads to medical errors, higher costs, and unnecessary pain for patients and their families.
Resident Match Program 2009
Facts on US NursesMost numerous health care workersShortages driven by demand and contextLargest supply in worldU.S. needs more BSN
Aiken et al. (2003) JAMA Variation in basic preparation
BSN, AD, Diploma
U.S. Nurse Shortage
By 2020, the demand for RNs will be 2.8 million equaling a shortage rate of 29%
Bureau of Health Professions, July, 2002
Registered NursesLicensed by stateLicensing Exam- NCLEX
London, Hong Kong726 per 100,000 personsMost employed in hospitals8% with advanced degrees88.4% white, 94.3% womenHRSA Health Professions Workforce Nursing Reports
Advanced Practice Nurses2004
Nurse PractitionersClinical Nurse Specialists
Specialty Care & Mental Health
Nurse AnesthetistsNurse Midwives
Interlocking cases that addressed historical questions
Relationship between private and public initiatives in practice and education
Political rhetoric of the professional organizations
Influence of gender , race, and class in the generation of new roles and knowledge
Influence of the patient
The importance of personalities
Workforce
Nurse Practitioners46, 328 (1992)63, 191 (1996)85, 000 (2000)141,209 (2004)
Clinical Nurse Specialists25, 000 (1995)72,521 (2004)
2004 Nurse Sample Survey
Policy Implications
Individual-generated patient demand for different models of care can move ideas forward to coalesce to health policy changes.
These changes can be piecemeal and at times inadequate to support large scale reform in the delivery system.
Greater access for patients to nurse practitioner models rests on real and virtual boundary disputes
Policy implicationsDevelop delivery models organized around the
care needed rather than around the type of practitioner who will deliver it.
Look to the large available pool of primary nurse practitioners to work as partners and collaborators rather than ancillaries.
What do NPs do?“Patient Centered”
Assessment DiagnosisTreatmentCase Management/coordination of care/integrationContinuity and secure transmission across the health
systemEmotional supportAccess“Whole Person”…Family and Community focus
Limitations to Access Scope of practice Payment Competition vs..
Collaboration Licensure/Certification Autonomy Prescriptive authority
U.S. Health Care WorkforceSelected Primary Care Clinician Supply
Source: Cooper RA, et al JAMA 1998; 280:788-94 and COGME’s Eighth Report, November 1996.
Clinically significant questions focused on health policy issues :
How do we decide who provides particular types of care at particular times and places?
Difference in response
Between organizations and
individuals
AMAAAFPAAPOsteopaths
Investigations by state boards of medicine, Prosecution of physicians who collaborated,Political lobbyingDemand for evidence
NP Policy ResearchGMENAC Report – 1980
complement vs.. substitute
nursing has independent sphere of practice
quality primary care accepted by patients
cited Kaiser study (75% all visits)
need for Medicare & Medicaid reimbursement
OTA Report - 1986 High quality of care Patient satisfaction Good potential for
managed care Barriers - physician
resistance, legal restrictions, lack of reimbursement, limited coverage for health promotion/preventive care
NP Policy Reports - 1990s1995 GMENAC Report Joint meeting Integrated Requirements Model Need for 12-24% increase in NPs
1997 HRSA Report on NP Preparation Access to primary care Increase in NP program support
Societal AcknowledgementsHCFA removed Medicare requirement of physician
supervision for nurse anesthetistsNPs in all states can dispense drug samplesHarvard Business Review - resistance to NPs is “flawed
logic,” “disruptive technology” IOM identifies NPs as primary care providersMedicare identifies NPs as primary care providersState reform initiatives: NPs as key componentsHealth reform bills: all include NPs as primary care
providers
NP Outcome StudiesOTA Report - 1986Naylor et al., 1994 - Transitional care modelMundinger et al., 2000 (RCCT)Larkin (2003)- patient days, days on ventilators,
complicationsLaurent, Reeves, Hermens, et. al. (2006) –
Cochran data Base Review (substitution of physicians by nurses)
Medicare Payment Percentage For virtually all services in all settings, Medicare
will cover PAs, APNs at 85% of the physician fee schedule
Services are billed at the full rate. Use of the PAs/APNs provider number triggers the 85% payment
[Medicare Transmittal AB-98-15]
“It’s the delivery system, stupid”
4/5 Americans with health insurance cannot find a primary care provider
NYT 2009 Major source of bankrupt individuals; medical billsMain increase in Medicare expenditures 1987- 2002???
(Thorpe and Howard, Health Affairs 2006)
Many models tried: CCM Disease Management Case Management Guided Care Geisinger’s Personal Health Navigator (Paulus, et.al. (2008)
Health Affairs
Consider:Not enough primary care physiciansWhy not NPs?Culture/structure: “tyranny of the urgent” (Berenson,
et.al. (2008) Health Affairs
Where do NPs fit in current health care reform debates?Senate and House bills
House “Affordable health Care for America Act” passed by 5 votes
Senate “Patient Protection and Affordable Care Act” in debate with political issues such as abortion, public option going to be key
Demonstration projects Medical home Regional consortiums
Funding for primary care educationCompanion bills:
Faculty support
Proposed Medicaid changesIncrease patient poolFunding for FQHC/safety net clinics
Nurse managed clinicsBirthing centers
Other changes:Medical home language:
from physicians to physicians, nurse practitioners, and physician assistants
What’s Not AddressedScope of practiceLicensureEquitable pay for equitable services
Making Room in the Clinic
Modern health care depends upon:Nurses, physicians, and patients working
togetherfinding common groundputting patients firstknowing how to use the skills and
knowledge of providers across time and place