Ann E. Teske, PhD, RN, Associate Professor, Department of Nursing, Otterbein University Heather Reed, MA, Primary Care and Rural Health

Transcription

1 Ann E. Teske, PhD, RN, Associate Professor, Department of Nursing, Otterbein University Heather Reed, MA, Primary Care and Rural Health Administrator, Ohio Department of Health

2 Exploratory Descriptive Study to Ascertain Changes in Roles and Utilization of APRNS in Critical Access Hospitals (CAHs) in Ohio since designation. Presentation at Ohio Flex Critical Access Hospital meeting, August 26, IRB approval by Otterbein University, September, Letters sent by Ms. Reed to all 34 hospitals requesting gparticipationp Confidentiality of information Approval of use of identifying information Structured interview attached Structured interview attached 31 traditional CAHs agreed to participate (94%)

3 Methodology, cont. 20 item structured interview by Dr. Teske (50% face to face and balance by phone) Interviews 10/09 through 1/10 Summaries were sent within one to two weeks of interview by to nurse administrator. Summary modifications/approvals als received ed by 3/10.

4 Critical Access Hospitals (CAHs) Application through ODH & HIFCA and federal site visit 25 acute/extended beds (At start only 15 acute) Medicare at reasonable costs for inpatient & outpatient services 101%. Not subject to Inpatient t Prospective Payment Systems (IPPS) and Hospital Outpatient Prospective Payment System (OPPS) 96 hours or less for acute care must transfer to larger hospital on contract & contract for quality improvement program. 24/7 emergency departments Full range of health services Hospitals in Ohio gained CAH status tt Jan Dec. 2005

5 Ohio s Critical Access Hospitals WILLIAMS FULTON LUCAS OTTAWA LAKE GEAUGA ASHTABULA DEFIANCE PAULDING VAN WERT HENR Y PUTNAM ALLEN AUGLAIZE MERCER DARKE PREBLE BUTLER SHELBY MIAMI WOOD HARDIN SANDUSKY SENECA HANCOCK WYANDOT CRAWFORD LOGAN CHAMPAIGN MONTGOMERY GREENE HAMILTON WARREN CLARK CLINTON BROWN CLERMONT UNION MARION DELAWARE ERIE MORROW HURON RICHLAND KNOX LICKING MADISON FRANKLIN FAIRFIELD FAYETTE HIGHLAND ADAMS PICKAWAY ROSS PIKE SCIOTO HOCKING VINTON ASHLAND WAYNE HOLMES CUYAHOGA LORAIN SUMMI MEDINA T PERRY JACKSON GALLIA COSHOCTON MUSKINGUM GUERNSEY ATHENS MEIGS MORGAN P0RTAGE STARK TUSCARAWAS NOBLE WASHINGTON CARROLL HARRISON TRUMBULL MAHONING COLUMBIANA BELMONT MONROE JEFFERSON Certified Critical Access Hospitals (CAHs) LAWRENCE

6 Hamric s Model for Advance Practice Nursing Primary Criteria Graduate Education/Certification/Practice Focused on Patient/Family Central Competency Direct Clinical Practice Core Competencies Expert Coaching & Guidance/Consultation/Research/ Leadership/ Collaboration/Ethical Decision Making Critical Environmental Element Affecting APN Regulatory & Credentialing Requirements/Business Aspects/Health Policy/Payment Mechanisms/Outcome Evaluation & Performance Improvement/Marketing & Contracting/Organ. g Structure & Culture

7 Results Demographics Dil Daily census ranged from 2 to 19 patients t per day with average patients and median of 12 Increase in ED use due to economic downturn and closing of rural manufacturing plants. 80% average hospital income from outpatient 80% average hospital income from outpatient services

8 Changes g in APRN Positions since CAH Designation 17 hospitals have had no significant changes (55%) (3 have no APRNs now or at designation) 14 hospitals reported increase in CRNAs and CNPs (45%) 1 hospital no longer has CRNAs 1 hospital had a CNM retire and has not had a replacement.

9 Roles and Utilization of APRNs Current APRNs employed or contracted by 31 CAHs include: 47 CRNAs 24 CNPS (with additional community CNPs with hospital privileges) 1 CNM employee (3 CNM in private practice with hospital privileges) No CNSs 18 Hospitals (58%) reported that all anesthetics are administered by CRNAs.

10 Job Description CNPs Components Found in CNP Position Descriptions n=17 Scope and Essential Functions 100% General Position i Summary 88% Job Knowledge and Skills 76% Certification of Authority as CNP by Ohio Board of Nursing 59% General abilities/personal traits 59% MSN 47% Quality Assurance Provisions 29% Nursing Staff Advanced Cardiac Life Support (ACLS) 24% Contract Terms 18% Required CE to maintain licensure and certification 12%

11 Salaries of CNPs and CRNAs CNP salaries were reported by 14 hospitals Low of $62,400 ($30/hr) to high of $130,000 ($62.50/hr) Base salaries with bonuses for productivity. Do not include benefits or malpractice insurance. Mean salary: $84,746 with median $84,167. CRNA salaries 17 part of larger service contract t and 8 employed as CRNAs. Latter group provided data. Range from $140,000 ($67.31/hr) to high of $218,400 ($105/hr) Mean salary: $179,550 and median was $179,000.

12 Physician Assistants 7 hospitals employ PAs. 7 additional hospitals have contracts with ih physician i groups for ED coverage that includes PAs. Areas of service: ED, urgent care, surgery, family planning clinic, internal medicine with hospitalist, and occupational medicine. 6 job descriptions from 5 hospitals. 4 required Master of Physician Assistant Program. Salaries: range from $62,400 to $110,000. Mean salary was $91,280 9, with a median of $95,000.

13 Changes & Benefits of APRNs 12 hospitals reported double digit increases (10 20%) in outpatient services since CAH designation Increase in ED use by 7 hospitals; only 2 hospitals reported increased inpatient utilization. APRNs have allowed hospitals to expand services further into their counties. Two hospitals benefit from 9 CNMs in large practices to provide OB/GYN services. This is especially welcomed in Amish communities. 20 hospitals indicated CRNAs provide valuable support to surgical services with 58% having no anesthesiologists.

14 Changes & Benefits cont. CNPs employed by 10 hospitals provide primary care in outpatient settings 1 CNP is working in ED/Urgent Care 2 CNPs (separate hospitals) are working with hospitalists to provide care and coverage. 5 administrators i noted that CNPs in private practice expand access to care and reduce use of ED while providing hospital referrals.

15 Challenges Although turnover rate for nursing staff ranged from 2 to 11% with 10 hospitals reporting g4% or less, concern for APRNs recruitment & retention. How to provide competitive salaries with DNP if reimbursements remain flat? CMS needs to provide 100% reimbursements for similar services. Limited career promotion opportunities Finding employment for trailing spouses Wage and tuition freezes have resulted in some APRNs CNRAs and CNPs leaving to join group practices.

16 Challenges, cont. 4 hospitals reported strong resistance by local physicians in recruiting CNPs want family practice physicians instead. (recruitment/retention problems) The opposing physicians give the following reasons: Prefer PAs as they see them more as their assistants rather than in independent practice. Have to cover them when they are on call so fewer days off. Concern over their malpractice insurance for supervision ii responsibilities.

17 Challenges, cont. Discussions included the pending Affordable Care Act on nursing education and practice. APRNs ability to work to their fullest potential. Need for nationalized standards of practice rather than each state deciding Ohio being one of the more conservative in scope & practice affects recruitment & retention. 100% reimbursement for Medicare and Medicaid rather than usual 85%. Concern over additional patient volumes due to Affordable Care Act and reimbursements.

18 Positive Stories One hospital was preparing p marketing plan for RN who had moved away and was returning as CNP. Word spread in the community and she had two months of appointments before the first brochure was disseminated. A CNP was hired to cover two office practices neither physician i had any experience with ih a CNP. (Role relatively new for community). One physician left for two weeks (meeting/vacation) and came back to a well organized office, reviewed charts concurred, and happy practice not one complaint. Physician went to hospital and asked for her full time.

19 Positive Stories, cont. Team of hospitalist, CNP, and pharmacist make rounds has been highly effective and has resulted in increased admissions. Holistic care is a hallmark of her work and she spends time in educating her families and coordinating social services. We have helped to finance a RN s education to become a CNP and she came back to a strong welcome from the community.

20 Strategic Plans for APRNS by Hospitals 24 hospitals (77%) are planning to hire/contract for 23 CNPs with an emphasis on family nurse practitioners. 16 positions would expand outpatient services such as endocrinology, cardiology, and wound care. 2 positions would provide after hours clinic support to discourage ED use. 3 positions to supplement ED staffing. 1 position for admission i histories/physicals i h i as well as support hospitalist physician. 2 positions as inpatient acute care.

21 Strategic Plans, cont. 3 hospitals have plans to hire CNSs: To assist st in gaining g Magnet Status Patient care and staff development Hospital admissions histories & physicals Take some night on call rotations to support physicians.

22 Considerations in Development 5 hospitals are considering developing rural health clinics. (2 from existing physician practices) Administrators at 4 hospitals are considering CNP/PAs to work with hospitalists in medicalsurgical areas, provide additional coverage in ED departments, and to support outpatient services. One hospital is considering hiring a CNM for additional Ob/GYN services to support Amish community as have been unable to recruit a female OB/GYN.

23 Addressing Need for DNP for Certification of APRNs All 31 hospitals have tuition reimbursement. Range is from $1,600 to $6,000 per year. Concern was repeatedly voiced that the DNP may price APRNs out of jobs unless Medicare & Medicaid reimbursements are enhanced. DNP will make it harder to recruit APRNs with competitive wages, professional support, and continuing education. None of the hospitals will require the DNP until Ohio law requires it. Question: How will the DNP impact scope of practice?

24 Study Limitationsit ti Three of the CAHs in Ohio did not participate. (9%) Two of full service CAHs in Ohio did not participate(6%) One is a rehabilitation facility. Reluctance of human resource departments to share job descriptions and salaries limited scope of study. Reason provided: not in best interest of the hospital to share this data even when nursing administrator had requested the information.

25 Conclusions The critical access hospital designation has provided hospitals with the means to employ and contract t with APRNs in moderately increasing numbers. APRNs are providing expanded access to health care services in their rural communities. APRNs are well received by hospital staff, some physicians, and communities once in place. The preference remains for physicians while small rural hospitals find recruitment and retention of physicians, particularly family practice physicians, more challenging due to low Medicare and Medicaid reimbursements.

26 Conclusions, cont. Concern by hospital administrators of the impact on wages and continuing i education that the DNP prepared APRNs will require. As salaries increase, they will be comparable to newly graduating physicians and hospitals will always choose the physician. APRNs in this study have all been very well received and acknowledged as providing high quality care. Strategic plans include expanding APRNs in hospitals to include all four categories: CNPs, CRNAs, CNSs, and CNMs with increasing focus on inpatient services.

27 Conclusions, cont. Among some administrators and physicians, there is a blurring of roles between APRNs and PAs due to prescriptive authority gained by PAs. Small hospitals are dependent on their physicians good will and physicians have significant influence on hospital operations. (Implications for hiring APRNs) 3 hospitals have no APRNs although one nursing administrator has been gently encouraging through education of physicians (Administration is supportive) on roles.

28 Implications/Questions for Education/Practice of APRNs in CAHs Education: Small rural hospitals will need public support (federal and/or state) to assist nurses to finance their DNP graduate education. What will the cost/benefit ratio be of the expenditure for education and salaries based on Medicare, Medicaid, and private insurance reimbursements? How best to support continuing education for APRNS and RNs in rural areas with limited financial i resources?

29 Implications/Questions, cont. Practice: APRNs are required graduate education and national certification i to practice in almost all states. National scope of practice, similar to that provided to physicians, would aid in educating the public and medical communities of their roles as well as assist in recruitment. Currently, Ohio is one of the more restrictive states for scope of practice and APRNs often leave for less restrictive states.

30 References Center for Medicare and Medicaid Services. Fact Sheet: Critical Access Hospital; 2008, April. Available at cesshospfctsht.pdf. Accessed on June 17, Ohio Hospital Association. Critical Access Hospital members; Available at: l. Accessed July 18, U.S. Department of Health and Human Services, Health Resources and Services Administration. Find shortage areas: HPSA by state and county Ohio. Available at: Accessed Otb October 6, 2010.

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32 American Association of Colleges of Nursing. AACN position statement tt t on Practice Doctorate t in Nursing; Available at: p/ / /p / p Accessed on July 14, APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee; 2008, July. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education. Available at: _ p _ 0708_w._Ends_ pdf. Accessed July 8, 2009.

33 Furlong E, Smith R. Advanced nursing practice; Policy, education, and role development. J Clin Nurs 2005; 14: U.S. Department of Health and Human Services, Health Resources and Services Administration. National Advisory Council on Nurse Education and Practice: First Report to the Secretary of Health and Human Services and the Congress; Available at: ftp://ftp.hrsa.gov/bhpr/nursing/firstreport.pdf. Accessed October 6, Christian, S., Dower, C., & O Neil, E. (2007a, December). Overview of nurse practitioner scopes of practice in the United States. USCF Center for the Health Professions, Retrieved from andsources/content.aspx?topic=overview of Nurse of Practitioner Scopes of Practice in the United States.

34 Christian, S., Dower, C., & O Neil, E. (2007b, Fall). Chart overview of nurse practitioner scopes of practice in the United States. USCF Center for the Health Professions, 1 8. Retrieved from and sources/content.aspx?topic=overview of Nurse Practitioner Scopes of Practice in the United States. P i th St t Bauer JC. Nurse practitioners as an underutilized resource for health reform: Evidence based demonstrations of cost effectiveness. J Am Acad Nurse Pract 2010; 22:

35 Hagopian A, Johnson K, Fordyce M, Blades S, Hart LG. Health lh workforce recruitment and retention in Critical ii Access Hospitals. CAH/FLEX National Tracking Project, University of Washington; Available at track/. Accessed June 29, Lea, J., & Cruickshank, M. (2005). Factors that influence the recruitment and retention of graduate nurses in rural health care facilities. Collegian, 12(2), Ohio Administrative Code. Chapter Advanced practice nurse certification and practice. Available at: 8. Accessed October 3, 2010.

36 U.S. Department of Health and Human Services, Health Resources and Services Administration. The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Available at: nssrn2008.pdf. Accessed on October 6, Institute of Medicine. The future of nursing: Leading change, g, advancing health; 2010, October. Available at: 010/The Future of Nursing/Future%20of%20Nursing%202010%20Report N i % % %20Brief%20v2.pdf. Accessed November 4, 2010.