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

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Nurses, Advanced Practice Nurses Workforce for
the 21st Century

• Julie Fairman, PhD, RN, FAAN
• Professor
• RWJ Investigator in Health Policy
• Director, Barbara Bates Center for the Study of
  the History of Nursing

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Health Reform Dilemmas

• Payment
• Access
• Quality
• Cost
• Provider Supply

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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

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• 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
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Not Enough Primary care physicians
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nursesparticularly effective at improvisation,
invention.
NY VNA, circa 1900, VNA Coll.
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Loretta Ford Collection
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Innovative Experiments 1965 Duke University
PA Program Charles Hudson Thelma Ingles
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Who shall provide care?????
Nurse
Doctor
Dietician, Social Worker, etc.
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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.

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Borderlands
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Context

• The 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.
• Its easy for important aspects of a patients
  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
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Facts on US Nurses

• Most numerous health care workers
• Shortages driven by demand and context
• Largest supply in world
• U.S. needs more BSN
• Aiken et al. (2003) JAMA
• Variation in basic preparation
• BSN, AD, Diploma

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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

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Registered Nurses

• Licensed by state
• Licensing Exam- NCLEX
• London, Hong Kong
• 726 per 100,000 persons
• Most employed in hospitals
• 8 with advanced degrees
• 88.4 white, 94.3 women
• HRSA Health Professions Workforce Nursing Reports

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Advanced Practice Nurses2004

• Nurse Practitioners
• Clinical Nurse Specialists
• Specialty Care Mental Health
• Nurse Anesthetists
• Nurse Midwives

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• 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

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Workforce

• Nurse Practitioners
• 46, 328 (1992)
• 63, 191 (1996)
• 85, 000 (2000)
• 141,209 (2004)
• Clinical Nurse Specialists
• 25, 000 (1995)
• 72,521 (2004)

2004 Nurse Sample Survey
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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

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Policy implications

• Develop 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.

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What do NPs do?Patient Centered

• Assessment
• Diagnosis
• Treatment
• Case Management/coordination of care/integration
• Continuity and secure transmission across the
  health system
• Emotional support
• Access
• Whole PersonFamily and Community focus

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Limitations to Access

• Scope of practice
• Payment
• Competition vs.. Collaboration
• Licensure/Certification
• Autonomy
• Prescriptive authority

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U.S. Health Care WorkforceSelected Primary Care
Clinician Supply
Source Cooper RA, et al JAMA 1998 280788-94
and COGMEs Eighth Report, November 1996.
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• Clinically significant questions focused on
  health policy issues
• How do we decide who provides particular types of
  care at particular times and places?

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• Difference in response
• Between organizations and
• individuals

• AMA
• AAFP
• AAP
• Osteopaths

Investigations by state boards of medicine,
Prosecution of physicians who collaborated, Polit
ical lobbying Demand for evidence
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NP Policy Research

• GMENAC 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

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NP Policy Reports - 1990s

• 1995 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

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Societal Acknowledgements

• HCFA removed Medicare requirement of physician
  supervision for nurse anesthetists
• NPs in all states can dispense drug samples
• Harvard Business Review - resistance to NPs is
  flawed logic, disruptive technology
• IOM identifies NPs as primary care providers
• Medicare identifies NPs as primary care providers
• State reform initiatives NPs as key components
• Health reform bills all include NPs as primary
  care providers

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NP Outcome Studies

• OTA Report - 1986
• Naylor et al., 1994 - Transitional care model
• Mundinger et al., 2000 (RCCT)
• Larkin (2003)- patient days, days on ventilators,
  complications
• Laurent, Reeves, Hermens, et. al. (2006)
  Cochran data Base Review (substitution of
  physicians by nurses)

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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

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• Its the delivery system, stupid

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• 4/5 Americans with health insurance cannot find a
  primary care provider
• NYT 2009 Major source of bankrupt individuals
  medical bills
• Main increase in Medicare expenditures 1987-
  2002??? (Thorpe and Howard, Health Affairs
  2006)
• Many models tried
• CCM
• Disease Management
• Case Management
• Guided Care
• Geisingers Personal Health Navigator (Paulus,
  et.al. (2008) Health Affairs

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Consider

• Not enough primary care physicians
• Why not NPs?
• Culture/structure tyranny of the urgent
  (Berenson, et.al. (2008) Health Affairs

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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 education
• Companion bills
• Faculty support

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Proposed Medicaid changes

• Increase patient pool
• Funding for FQHC/safety net clinics
• Nurse managed clinics
• Birthing centers
• Other changes
• Medical home language
• from physicians to physicians, nurse
  practitioners, and physician assistants

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Whats Not Addressed

• Scope of practice
• Licensure
• Equitable pay for equitable services

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Making Room in the Clinic

• Modern health care depends upon
• Nurses, physicians, and patients working
  together
• finding common ground
• putting patients first
• knowing how to use the skills and knowledge of
  providers across time and place

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