Health Policy Fellowship Group Assignment Rural Health June 2014 Expanding Access to Primary Care in Rural Areas

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1 Health Policy Fellowship Group Assignment Rural Health June 2014 Expanding Access to Primary Care in Rural Areas Increasing Access to Primary Care In 2007 Nebraska passed legislation, An Act Relating to Ensuring Success in Health Care Reform. One section, Support for Primary Care Providers, calls for a task force to study and make recommendations on the advisability of eliminating the requirement for an advanced practice nurse to work in a collaborative practice with a licensed physician, with the goal of evaluating whether advanced practice nurses might serve a greater role as primary care providers who provide essential chronic care management. Even though Nebraska does not plan to expand Medicaid, the increase in access to health care via the state s federally-run health care exchange has moved this issue to the front burner. Nebraska has a shortage of providers and is seeking ways to increase access to primary care both in underserved rural areas and in urban areas. Eighteen Nebraska counties have no physicians, and 15 counties have no health care providers at all. Nebraska is predicting a nursing shortage of 5,300 RNs by 2020 and a shortage of 380 physicians as of The Task Force The task force is made up of representatives from the office of the Commissioner of Health (1); the Director of the State Office of Professional Regulation (1); Nebraska APRN Board of Nursing (2); Nebraska legislature (1); Nebraska consumers (1); UNE Medical Center School of Nursing (1); Nebraska Medical Practice Board (1); Nebraska Medical Society (3); Nebraska Nurse Practitioner Association (1). While consensus among task force group members is encouraged, it is not mandatory. The task force can present both the majority and dissenting conclusions. Your Audience The task force will advise the Chairs of the Nebraska House and Senate Committees of Health and Human Services who are considering legislation that seeks to nullify the statute requiring an Integrated Practice Agreement between an NP and collaborating physician, and seeks the legal right for NPs to be listed on provider panels as Primary Care Providers (in order to make possible third party reimbursement). The Legislative Process According to State Regulation of Nurse Practitioner Practice (Jones and Bartlett) The law governing NP definition, scope of practice, prescriptive authority, and requirement of physician

2 collaboration (if any) may be enacted by a state legislature in great detail or in general terms. Alternatively, the state legislature may give authority to a licensing board to make the rules and regulations that will govern NPs. In Nebraska the APRN Board licenses and regulates the profession under the direction of the Nebraska DHHS Division of Public Health. In order to change a statute, an advocate must enlist the help of a state legislator to introduce a bill. Much of the state law governing NPs appears in regulation; some law is statutory. The practice issues that come under state regulation include the following: Requirement for licensure Scope of practice Prescriptive authority Requirement of collaboration or supervision Basis for license suspension Reimbursement under Medicaid Reimbursement by indemnity insurers Requirements for educational programs Standards of practice Nebraska s Current State Regulations of NP Practice and Prescription Rights RN license Evidence of successful completion of an approved advanced practice registered nurse program Evidence of having completed 30 contact hours of education in pharmacotherapuetics Submission of proof of having passed an examination pertaining to the specific advanced practice registered nursing role in nursing adopted or approved by the boards Masters of doctorate in nursing Completed APN program Demonstration of separate course work in pharmacotherapuetics, advanced health assessment, and pathopsychology Completion of minimum of 2000 hours of practice under the supervision of a physician An intergreated practice agreement with a collaborating physician Professional liability insurance. State Regulation of Nurse Practitioner Practice (Jones and Bartlett)

3 Task Force Commissioner of Health (1): Cynthia Kelley Nebraska APRN Board of Nursing (2): Lauren Donatelli Seyler and Maria Plummer Nebraska legislature (1): Rob Richardson Nebraska consumers (1): Brian Marshall UNE Medical Center School of Nursing (1): Pamela Grimaldi Nebraska Medical Practice Board (1): Monte Mitchell Nebraska Medical Society (2): Donna Emanuele, Jeanne Rupert Nebraska Nurse Practitioner Association (1): David Levine The task force will have 15 minutes to present and 15 minutes for Q/A on Sunday, March 30, 2014, in Denver, Colorado. Elements of negotiation might enter into your discussion. Guidelines from Getting to Yes might be helpful: The Task Force will Agree on objectives; List the interests it will pursue during negotiations (musts and wants); Identify as many options as possible for mutual gain; List its perception of the interests of the other groups (musts and wants); Identify as many options as possible for mutual gain regarding the interests of the other groups; Select objective criteria that can be used as a fair standard. Develop BATNAs

4 Tips for Uncovering Interests Christy Vincent, Ph.D. Page 34 When faced with a particular demand or statement of position, refuse to react negatively to the demand. Avoid making a demand or stating a position. Rather, begin asking questions to uncover the interests. 1. What are your key concerns? 2. Help me understand why this is really important to you. 3. You say Tell me more about that. 4. Could you walk me through this step by step? 5. What will it achieve for you if we? 6. Have I misunderstood your interests? What am I missing? 7. As I understand, your interests are When listening for interests, summarize periodically to let others know they are understood. 1. Let me make sure I understood you. Your interest is. Am I right? 2. From your perspective, we should. Is that accurate? 3. Let s see if I can review the key points we have discussed. Did I understand you correctly? Attempt to ensure you have gotten below the surface on an issue by asking questions for clarification. 1. How much of a concern is this? 2. How does this compare to other situations? 3. Can you give me an example? When coaching other people in conflict situations, ask questions to uncover interests and possible solutions (Wilmot & Hocker, 2011). 1. What is in your way that makes it so you can t cooperate? 2. What do you want? What would it mean if you got it? 3. What are two other ways you can get what you want? 4. Can you tell me why you feel so strongly about this? 5. Before this conflict started, what did you want? 6. If you could have anything you wanted, what would it be? 7. If she or he would apologize, what would that do for you? 8. What process could be used to keep you involved and on board? 9. What problems are we trying to solve? 10. What could the other do or say that would impact you? 11. What is your goal?

5 Material taken from Stone, Patton & Heen (2000). Difficult Conversations: How to Discuss What Matters Most and Wilmot and Hocker (2011). Interpersonal Conflict.