Nurses, Advanced Practice Nurses: Workforce for the 21st Century

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