August 20, 2013

Nurse Practitioners: Breaking Down

Barriers to Practice

Joanne T. Clavelle DNP, RN, NEA-BC, FACHE

Vice President, Patient Care Services

Chief Nursing Officer

August 23, 2013

Nurse Practitioners of Idaho 2013

Annual Fall Conference

Objectives

• Understand context for Nurse Practitioner (NP) practice:

IOM Future of Nursing Report

Elements of the Accountable Care Act (ACA)

Regional trends increasing demand

• Cite common barriers to NPs practicing to their full scope of

practice

• Review St. Luke’s case study:

Apply a collaborative organizational change model to

promote expanded privileges across the care continuum

Foster collaborative relationships with medical staff in

designing new models of care

• Examine service/academic partnerships and impact upon NP

supply

• Identify resources to lead through assessment and change

• Questions

2

Context for Practice

• IOM Future of Nursing Report

Blueprint to transform nursing practice, patient

care & education

Nurse leaders participate in redesign and

improvement in full partnership with physicians

Ensure that nurses can practice to full extent of

their education and training

Improve data collection for workforce planning

and policy-making

IOM Future of Nursing Report

• Messages

Nurses should be able to practice to full extent

of their education and training

Nurses should be full partners with physicians

and others in redesigning U.S. health care

• Recommendations

Remove scope-of-practice barriers

Expand opportunities for nurses to lead and

diffuse collaborative improvement efforts

CNO Context for Practice

• Challenges of healthcare reform:

Assure safe, high quality, effective patient-

centered care

Position nurses as integral to design and

delivery

Design new nursing roles and care models

across care continuum

Value-based purchasing

Align with the Triple Aim

Workforce shortages

Positioning for Accountable Care

• Group of physicians, hospitals and providers that come

together to deliver coordinated, high-quality care to Medicare

beneficiaries

• St. Luke’s ACO was created to participate in the Medicare

Shared Savings Program (MSSP)

• Goals

Improve quality

Improve patient experience

Coordinate care

Improve patient safety

Improve health/manage populations

• Full Risk Medicare Advantage Programs

• Preparing for state health insurance exchange and expansion

of Medicaid

6

Positioning for Accountable Care

• SelectHealth & Clinical Integration

Payer partnership

Employed and independent providers aligned across the

continuum

Best practices, clinical guidelines, standard order sets and

contracts with SNIFs, LTACHs, Rehab and Behavioral

Health

Care management & coordination

Managing care transitions

Medical homes & care of patients at risk (CoPar)

• Integrated electronic medical record (EMR)

• Healthy U

7

Primary Care Medical Home

Accountable Care Organization

Why ACA Provisions Will Move Forward

• Republicans and Democrats

Agree >80%

• Lower cost

• Improved quality

• Greater access

• Focus on prevention and

wellness

• Patient Centered Medical

Home / ACO

• Can’t afford not to

What to Expect

Nationally ~

• ACA is here to stay

• Integration and coordination of care

• Cost reduction

• Quality of care NOT quantity of care

• More focus on health and less on health care

• Greater focus on primary care

• Greater focus on collaborative care

McGowan Peak, Sawtooth National Recreation Area, Central Idaho

State-wide/regionally ~

• Health insurance

Exchanges

• State/Regional Co-Ops

• Medicaid expansion

• Local primary care

• Community health

• Improved models of

collaborative care

• SHIP grant – assists

Medicare beneficiaries

understand benefits/plans

Idaho Workforce Rankings

Physicians per

Capita 49th

Primary Care

Physicians per

Capita

47th

Nurses per Capita 50th

Nurse Practitioners

per Capita 45th

Physician

Assistants per

Capita

Tied

14th

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho Nursing

Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Idaho Workforce Projections

Today 2018

Physicians 1,393 1,580

Primary Care

Physicians

777

862

Nurses 13,430 17,050

Nurse

Practitioners 441 560

Physician

Assistants 539 763

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho Nursing

Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho

Nursing Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Primary Care HPSAs

Health Professional Shortage Areas

- (county or service area)

(demographic – low income population)

St. Luke’s Treasure Valley

• Founded as a 6-bed frontier hospital in 1902

• Two hospitals (548 beds)

• 100 provider-based clinics

• Five regional cancer centers

• Home care & hospice services

• Three ambulatory surgery centers

• 2200 RNs/100 Nurse Practitioners

• 39th organization to receive Magnet®, 3rd 2011 designation

Professional Practice Model

14

Eight Steps to Creating Change*

• Establish a Sense of Urgency

• Create the Guiding Coalition

• Develop a Vision and Strategy

• Communicate the Change vision

• Empower Broad-based Action

• Generate Short-Term Wins

• Consolidate the Gains/Produce More Change

• Anchor New Approaches in Culture

*Adapted from: Kotter, J. Leading Change. Boston, MA: Harvard Business School Press; 1996

Establishing a Sense of Urgency

• Traditional medical staff philosophy of supervision

and restriction

Prohibited from admitting and discharging,

writing orders, H & Ps, rounding, diagnosing

• Clinic expansion, managing populations,

primary care provider shortages

• Expanding APRN privileges priority for both

physician and nursing leadership

August 20, 2013

Outdated Terms: Talking Points*

• Limited licensure providers

Unique, no “limit” outside of scope of practice as regulated by

Idaho Board of Nursing

• Dependent care providers

In Idaho, APRNs are independent; physician involvement not

required for practice. We support collaborative practice.

• Mid-level practitioner

Unique body of knowledge/scope, all practicing at highest level

under privileges granted from organization

• Physician extender

Professional nurses practice rooted in nursing body of

knowledge, physician provides medical care

One profession cannot “extend” another

Physician assistants are physician extenders as they practice

under the physician’s license and are regulated by the BOM

Adapted from J. Clavelle. SBAR on Nursing Practitioner Privileges. Boise, ID. 2010

Creating the Guiding Coalition

• CNO catalyst for change

• Validate vision: CEO, CMO and MEC Chair

agreeing to lead task force

• SBAR document for situational briefing

• Individual meetings with more than 20 physicians

• Selection of a professional facilitator

• CNO as nursing practice expert; no NPs

Developing the Vision and Strategy

• Nurse Practitioner privileges need to be revised in

order to:

Align with physician expectations regarding how

they collaborate to care for patients across the

care continuum

Reflect current IBN scope of practice

Place St. Luke’s in a better position for

accountable care and achieving vision of

partnering with providers to achieve patient-

centered, quality, integrated care

• Nursing strategic plan - Goal

Communicating the Change Vision

• SBAR to convey vision and educate on outdated

terms

• Supervision of practice not aligned with scope

• MDs and NPs have separate, but related body of

knowledge

• CNO as highest level authority and practice expert

– DNP

• APRNs and physicians work in partnership to care

for their patients

Empowering Broad-Based Action

• Core privileges

• Admission, discharge, H & P, consults, writing

orders, prescriptive authority

• Specialty privileges at department level

• Expedited process and approvals

• Significant dialogue on differentiating NPs and PAs

• Assessment of privileges in other organizations, review

of literature

• BON role and rules, nursing practice guidelines, peer

review

• Sponsoring vs. supervising for shared patients

Generating Short-term Wins

• One year process to achieve core privileges

• Immediate impact

- Nursing strategic goal achieved and celebrated

- Addressed IOM report recommendation

- Aligned with Magnet® model component of

exemplary professional practice

- Created new NP Forum

- Align with Schools of Nursing plans to expand APRN

and DNP programs

- Improve physician satisfaction and integration, e.g.

hospitalists, across clinics/hospitals

Consolidating the Gains

• CNO leadership ~ next steps

Continue to engage key stakeholders

Create operational framework to support practice,

e.g. NP peer review

Modify and approve of medical staff bylaws, medical

records policies, job descriptions, FPPE and OPPEs

Educate staff, leaders, physicians, community

Align with Regional Action Coalition

Develop service/academic partnerships

Emphasize role clarity and consistency of care and

practice across settings

Goal is long-term change in health and health care.

Recommendations

• CNOs must rise to challenge to lead and transform their organizations, influencing organizational policy to create change

• Partnering with physician colleagues integral to achieving outcomes

• Task force model effective at removing barriers to nurses practicing at their full scope of practice, improving clarity and meeting physician and nursing expectations

• Continue to develop new roles, structures and processes to achieve best outcomes for our patients and community

• Access organizational support: AARP, Idaho Regional Action Coalition, Robert Wood Johnson’s Campaign for Action, National Council of State Legislators Scope of Practice Tracking web site

References

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10. Kotter J. Leading Change. Boston: Harvard Business School Press; 1996.

11. Idaho Rules of the Board of Nursing 2012, http://adminrules.idaho.gov/rules/current/23/0101.pdf

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Questions?