“Putting Your Best Foot Forward” How Knowledge of Evolving Laws and Application of Collegial Collaborative Care Best Practices Provides the DNP Authentic Leader with an Opportunity to Transform Patient-Centered Health in line with National Health Care Goals

BARBARA J. DUPONT, JD, DNP, RN BALTIMORE, MARYLAND OCTOBER 5-7 , 2016

COPYRIGHT © 2016 BY BARBARA J . DUPONT

ALL RIGHTS RESERVED

GETTING TO KNOW YOU!

Acknowledgments

Acknowledgments

 

 

 

  A Graduate University of Health Sciences Founded by   Massachusetts General Hospital

DNP POWER HOUR: Transforming Healthcare Through Collaboration Through Collaboration

Purpose/Goal for this Presentation:

  This Presentation will broaden paths that promote collegial collaboration among all health care providers.

First Step: Be an Authentic DNP Leader

Characteristics of a DNP Authentic Leader v DNP authentic leaders are real and original - not a mere imitation. v DNP authentic leaders are not afraid to be authentic and take leadership risks. v DNP authentic leaders lead from conviction and lead ethically.

Stakeholder’s Shared Concerns • Expanding elderly and immigrant populations • Increasing demand for best practice primary care • Shortage of health care providers • Restrictions on our DNP/APRN scope of practice (AACN, 2006)

Introductory Collaborative Practice Concepts: Legal and Other Differences Within Specific Health Care Organizations

v Inter-professional collaborative organizations

v Multi-professional collaborative organizations

v  Intra-professional collaborative organizations

v The statutory collaborative agreement

Inter-professional Collaborative Organizations

Involves two or more healthcare providers, licensed in different professions, for example, physicians and DNPs/APRNs working with and, learning from, one another within any health care environment.

Inter-professional Collaborative Partnership Core Competencies (Interprofessional Education Collaborative Expert Panel, 2011).

1.  Patient/family centered (hereafter termed “patient centered”

2.  Community/population oriented

3.  Relationship focused

4.  Process oriented

5.  Linked to learning activities, educational strategies, and behavioral assessments

6.  that are developmentally appropriate for the learner

7.  Able to be integrated across the learning continuum

8.  Sensitive to the systems context/applicable across practice settings

9.  Applicable across professions

10.  Stated in language common and meaningful across the professions

11.  Outcome driven

Multi-professional Collaborative Organizations  Involves two or more licensed professionals working together, at least one of whom is from a non-healthcare profession, for example, lawyers, while learning with and from each other, regardless of their work place locations.

Intra-professional Collaborative Organizations

Involves two or more providers, licensed in the same health care profession, working with and, learning from, one another within any health care environment.

Who are the Key Stakeholders? • Patients • Family • Community (including licensing authorities) • Physicians • Lawyers • DNPs/APRNs • Others (For example: MBAs, CPAs, Professional Organizations) • Academicians and Educational Institutions • Social Workers

The Statutory Collaborative Agreement as a Potential Obstacle to Collaborative Partnerships and Legal Partnerships

Collaborative Agreements v  Is a legal instrument that is required from state to state, which embodies the parties’ operating agreement, including, among other provisions, written protocols between and among health care professionals practicing collaboratively. These instruments are to be distinguished from internships under the supervision of a physician or DNP/APRN by which DNPs/APRNs qualify for licensure in some states. For example: New York State Education Law, Art. 139, §6902 (3)(a)(i)(2015). v Collaborative operating agreements restrict practice and/or prescriptive authority, by and among, health care providers and establishes guidelines regarding prescriptive authority and scope of practice within the organization, with fixed terms and limitations on the supervisory authority.

Types of DNP/APRN Scope of Practice Laws • Highly restrictive (California, Guam, Georgia, Florida, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, and Virginia)

• Restrictive (Alabama, Arkansas, Delaware, Illinois, Indiana, Louisiana, Kansas, Kentucky, Massachusetts, Mississippi, New Jersey, Ohio, Pennsylvania, South Dakota, West Virginia, Wisconsin)

• Least restrictive (Arizona, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Iowa, Nevada, Oregon, Montana, Nebraska, New York, Maine, Maryland, Minnesota, New Hampshire, New Mexico, North Dakota, Rhode Island, Utah, Vermont, Washington, Wyoming)

Case Law and Other Health Policy Considerations v The Federal Trade Commission (“FTC”) (Dupont, 2014)

v Current case law:

North Carolina State Board of Dental Examiners v. Federal Trade Commission

135 S. Ct. 1101 (2015)

 Issue: The issue in this case was whether a state delegate to a board composed chiefly of dentists has power to regulate the scope of dental practice and its immunity from the federal anti-trust laws.  

v Political recognition of public demand for change in scope of practice laws: Multi-state pending legislative reform.

Types of Business Organizations (Jural Entities) 1. Sole Proprietorship (Or “DBA” – doing

business as) 2. Corporation 3. Professional Corporation (“PC”) 4. Limited Liability Company (“LLC”) 5. Professional Limited Liability Corporation

(“PLLC”)

Types of Business Organizations (Partnerships) 6. General Partnership 7. Limited Partnership 8. Limited Liability Partnership (“LLP”)

Common Health Care Organizations Functioning as Either Corporate or Partnership Legal Entities: 1.  Health Maintenance Organization (“HMO”) 2.  Patient Centered Medical Home (“PCMH”) 3. Nurse Managed Health Clinic (“NMHC”) 4. Nurse Managed Patient Centered Medical Home (“NMPCMH”) 5. Accountable Care Organization (“ACO”)

Factors Impacting Choice of Organization and Limiting Collaborative Barriers 1.  Avoidance of income taxes 2.  Conservation of costly managerial resources 3.  Limitation of liability, particularly defense of

malpractice claims, employee claims 4.  Casualty and life insurance (buy- sell agreements) 5.  Employment contracts:

-For-profit, not-for-profit -Academia

Recommended Collaborative Health Care Organization

A. The Professional Limited Liability Corporation (“PLLC”)

or A. The Limited Liability Partnership (“LLP”)

Benefits of PLLC or LLP Over Other Vehicles  A. Communications among providers is facilitated  B. Limited liability is achieved without a burdensome administrative structure required by corporate vehicles, lest limited liability is lost (“Piercing the Corporate Veil”)  C. Enhanced participation and greater flexibility in day-to-day decision making by collaborative practitioners

Barriers to Collaborative Practice (1) State restrictive scope of practice laws

(2) Discriminatory practices (3) Unfair competition (Federal Trade Commission (“FTC”))

History, Scope of Practice and Collaborative Arrangements

“There are two classes of people in the world....” Florence Nightingale

The Barriers Always Existed

“I tell what I have seen”

Dorothea Lynde Dix

Finding Solutions: Building Collaborative Relationships – “Good Fences make Good Neighbors”

Building Alliances for Enhanced Health Care at Reasonable Cost Mutual professional collaboration- As an authentic DNP leader YOU must ask: Who are the people with power? Who are the team members? Can we accomplish it?

How can we best build these alliances? What are the obstacles?

Many sterotypes still exist SOME OLD SOME NEW

Enhancing Collaborative Practice: Understanding Conflict Resolution Tools v Contractual clauses v Arbitration v Mediation v Litigation v Corrective legislation: a. Patchwork amendments b. Regulatory changes v Political recognition of public demand for change in scope of practice laws v Multi-state pending legislative reform v Case law

Benefits of Collaboration - the Goals and the Outcomes

• Patient outcomes - Enhanced delivery - Preventative care - Optimal health care outcomes -Reduced cost (as contemplated by the Patient Protection and Affordable Care Act, 2012) • Provider satisfaction - Professional responsibility - Equal compensation

Create a Culture for Collaborative Practice

Collaborative educational solutions :

v Collaborative partners must redefine holistic, patient centered nursing practice by all collaborative team members v Collaborative partners must understand emotional impact on team members (burnout) v Collaborative partners must understand that operations in uni-professional silos are often unsuccessful and diminish ability to share knowledge (trust, logistical obstacles) v Collaborative partners must understand that multi, inter and even intra collaborative partnerships may require different patient care ideologies and goals

Create a Culture for Collaborative Practice Starting Today v Advocate for synergistic inter, intra and multidisciplinary practice:

- Enhance provider competencies - Eliminate duplication - Effect cost savings

v Be an authentic leader: -Eliminate restrictive scope of practice laws -Insure full nursing participation before regulatory bodies -Create that PLLC or LLP vehicle as soon as possible

Conclusion

I Appreciate Your Kind Attention!

Questions and Comments  “Knowledge is Power” Sir Francis Bacon (1561-1626)

 A key to successful synergistic practice and enhanced leadership is knowledge

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