How To Evaluate The Cost And Patient Outcomes Of A Pediatric Nurse Practitioner

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1 Session objectives Analyze current trends in PNP education Examine early outcomes of dual track PNP programs Mary Berg, DNP, ARNP, CPNP-PC, FAANP Elizabeth Hawkins Walsh, PhD, RN, CPNP, PMHS Michelle Beauchesne, DNSc, CPNP, FAAN, FAANP Evaluate barriers and facilitators for implementation of dual PNP education Predict future trends in PNP education Disclosures Speakers have nothing to disclose. The Charge NP educators have a responsibility to provide programs that meet the changing health care needs of our population and Programs designed to meet the needs of the nurse practitioner workforce (IOM, Future of Nursing, 2011) What are those changing health care needs of our population? Increasing complexity Increasing chronicity Increasing acuity of pediatric health problems. Shift in pediatric visits from FP to Pediatric providers. For the first time more adolescents are being seen by pediatricians than FP >>>>>>>>>>> Increasing demand for PNPs from primary, specialty, and acute settings. What are the Issues impacting current pediatric nurse practitioner workforce? Demand is greater than ever and projected to grow for both primary and acute care PNPs Adoption of Consensus Model gradually affecting supply of NPs for pediatrics. Projections envision increased use of PNPs in variety of new primary care, subspecialty, acute, critical care, and rural settings ( Freed, 2010) While ACA has brought attention to need for more PCP, demand for PNPs by subspecialists often overlooked. Survey in 2011 found 69% pediatric subspecialists already worked with PNPs while 45% of pediatric PCP worked with PNPs (Freed, Dunham, Loveland- Cherry, Martyn, Moote.) Both groups predicted expanding roles for PNPs in near future ilikely ncreasing competition between generalists and specialists for limited pool of PNPs. 1

2 Examples BACKGROUND: This program evaluation sought to compare cost and pediatric patient outcomes among a pediatric nurse practitioner (PNP) hospitalist team, a combined PNP=doctor of medicine (MD) team, and 2 resident teams without PNPs. METHODS: Administrative and electronic medical record data from July 1, 2009 to June 30, 2010 was retrospectively reviewed from Children s Hospital Colorado inpatient medical unit and inpatient satellite sites in the Children s Hospital net-work of care (NOC). The top 3 All Patient Refined Diagnosis Related Groups (APR-DRG) admission codes bronchiolitis and respiratory syncytial virus (RSV) pneumonia, pneumonia not elsewhere classified (NEC), and asthma were selected for this analysis. A Crisis in PNP Workforce CONCLUSIONS: There is evidence to suggest that PNP hospitalists provide inpatient care comparable to resident teams at a lower cost for patients with uncomplicated bronchiolitis, pneumonia, and asthma. Aggregate NP workforce has nearly doubled in US since Nearly all the growth has been in population of FNPs FNPs are not the answer to the expanding complexity of needed pediatric services. PNPs were the first group of nurse practitioners and paved the way for subsequent groups, in role, recognition, and in reimbursement. Today PNPs only comprise 4.5% of NP population ****** Where are all the PNP Students? Proportion of NP Graduates by Clinical Track, Pediatric Nurse Practitioners in the United States: Current Distribution and Recent Trends in Training by Freed, Dunham, Loveland-Cherry, Martin,

3 At a time when NPs were not widely known and barriers were high, PNP comprised 100% of NPs in the country At a time when opportunities are expanding across the country and demand is growing, PNPs comprise 4-6 % of NPs in the country! What Do We Know So Far About Dual PNP Programs, Graduates, and Employers? Survey Results: Program Directors Average Program Age: 1.2 years Sample: 7 directors of dual/combined acute and primary care PNP programs Types of PNP programs represented: 4 with both Primary Care only and Acute Care only 3 with Primary Care and Acute Care available only as a post-master s certificate # of Programs Start Year of Dual/Combined Programs Year that Program Began # of Programs Average Program Length: 1.2 years Average Program Length: 2.17 years No response Program Length (years) # of Credits/Clinical Hours Required Program # Primary Care Acute Care Dual/ Combined Number of Shared Credits 1 39/540 44/ /600 45/600 55/ /625 52/875 52/ /520 40/600 49/ /600 54/ * 2 programs did not respond to this question 3

4 Placement of Dual/Combined Program Graduates by Setting 7% 17% 3% 13% 14% 46% Directors Average Perceived Success of Program Graduates Pass Rates 98.0% Employment Opportunities 99.5% Student Satisfaction 94.3% Employer Satisfaction 97.8% Primary care Acute care/icu Specialty Care ER Hospitalist Other * Only 3 programs responded to this question Survey of Program Graduates N = 13 graduates responded to survey Average time since graduation = 4.2 years Average time in current position = 4 years Order of certification exams taken: Primary care first Acute Care second: 91% Acute care first Primary Care second: 9% Program Graduates Ratings of Their Overall Impressions % Very satisfied or Satisfied Curriculum/coursework 10/13 = 77% Clinical experiences 11/13 = 85% Preparation for the certification exams 10/13 = 77% Preparation for current clinical position 11/13 = 85% OVERALL 11/13 = 85% Program Graduates Assessments: Adequacy of Experience/Placements % Saying Yes to Having Adequate Experiences/ Placements Primary Care 13/13 = 100% Acute Care 11/13 = 85% Specialty Care 12/13 = 92% Chronic Care 7/13 = 54% ER/Urgent Care 10/13 = 77% Program Graduates Placements by Acuity Level % of Graduates 100% 80% 60% 40% 20% 0% 38% 62% 33% 67% First Second Third Placement 100% Low Medium High 4

5 Survey of Employers Preference of Employers for PNP N = 48 respondents Identified by Program Directors, Graduates, and recruited from (Name of Professional Organization) On a scale of 0-100, prefer: Primary Care preparation: 56/100 Acute Care preparation: 53/100 Dual/Combined preparation: 69/100 Satisfaction of Employers with PNP Graduates reported Flexibility in Employment Choices On a scale of 1 (Very Dissatisfied) to 6 (Very Satisfied), Rate satisfaction with PNP Employees: Primary Care preparation = 6.00 Acute Care preparation = 5.75 Dual/Combined Acute and Primary Care = 5.76 Sample Employment Of Dual Graduates reported by PNP Directors Hospitalist Surgical Cardiology/Thoracic Oncology/Hematology Diabetes Genetics/Cystic Fibrosis Plastics/ENT Orthopedics Primary Care School Based Clinic Pain Management Palliative Care Home Based Care Military Special Needs Justice System Anecdotal reports from primary care PNP students who did not Continue in dual Track The Integration of acute care content in primary care courses strengthened our program s focus to better prepare us to care for the complexity of primary care today. We benefited from increased resources such as more radiology, inclusion of suturing class and simulation activities that were not offered before the addition of the dual approach. I learned more about end stage consequences of illness from the inpatient PNP perspective, which will make me consider those factors when determining care in a primary care setting-i guess it broadened my perspective and made me think more carefully about possible outcomes of my decisions. 5

6 Reports from Dual PNP students who initially considered acute care but chose Primary care I wasn t clear about what constituted primary care before I took these courses. I had only worked in a hospital setting and thought that was the role for me. I discovered that I loved working with kids in primary care, especially anticipatory guidance and health promotion. I never realized how much you had to know in primary care! Our professors kept telling us The buck stops here! And it does! but It is challenging and exciting and worth the pressure.- and I thought it would be boring! Students in dual track who initially thought Primary care but chose acute care I entered the dual program convinced that I wanted primary care but figured I would be more marketable with both certifications. I found I really liked the focus more in specialty clinics on becoming an expert on one topic so I chose to work in a neurology clinic but I still use all the primary care content. I was surprised at how much I enjoyed my specialty practice clinicals and the continuity approach of following children through outpatient to inpatient. At our children's hospital PNPs are employed by a service and we work with the pediatricians in all settings so this dual certification gave me an advantage. Hodge Podgeof Issues in NP Education and Marketplace for Reflection Diminishing Pediatrics in Undergraduate curriculum Proliferation online distance FNP programs FNPs now considering adding acute care tracks Most often adult/gero acute care not pediatric No current acute care FNP curriculum or competencies PAswho are not specific about primary care or acute care Interpretation of APRN Consensus Model by NCSBN grandfathering compact mobility from state to state Doctor of Nursing Practice options-opportunity or challenge? What is Being Done to Meet PNP Workforce Needs? Are Potential PNP Students Uncertain of Where They Hope to Practice? Of Where the Jobs will be? By forcing PNP students into choosing between Primary and Acute Care, are we discouraging applicants into PNP Programs? Can We Offer Students PNP Programs that Better Prepare Students for Growing Needs and Evolving Demands? What Have we learned from the Experience So Far of Dual Acute and Primary Care PNP Programs? Acknowledgement References: Jill Gilliland American Association of Colleges of Nursing. (2010) Update and implications for AACN member schools: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. American Nurses Association, National Association of Nurse Practitioners & Society of Pediatric Nurses (2008). Pediatric Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebook.org. APRN Joint Dialogue Group. Report, July 7, 2008: Consensus model for APRN regulation: Licensure, accreditation, certification & education. Washington DC: Author. Retrieved from Association of Faculties of Pediatric Nurse Practitioner Programs. (1988) Philosophy, conceptual model and terminal competencies for the education of pediatric nurse practitioners. Brooks, R.H. (2009). Disruption and innovation in health care. Journal of American MedicalAssociation,302 (13), Cajulis, C.B. & Fitzpatrick, J.J. (2007). Levels of autonomy of nurse practitioners in an acute care setting. Journal of the American Academy of Nurse Practitioners, 19, doi: /j x Chornick, N. (2008). Advanced practice registered nurse educational programs and regulation: A need for increased communication. JONA S Healthcare, Law, Ethics, and Regulation, 10(1), doi: /01.NHL CNA. (2005). Nurse Practitioner Claims Study: An Analysis of Claims with Risk Management Recommendations Retrieved from epractitionerclaimsstudy.pdf Dunn, L. (1997). A literature review of advanced clinical nursing practice in the United States of America. Journal of Advanced Nursing, 25, The Institute of Medicine. (2003). Health Professions Education: A Bridge to Quality. Washington, D.C. The National Academes Press. Institute of Medicine. Crossing the quality chasm: A new health system for the 21 st century. Washington, DC: National Academy Press: Kleinpell, R.M. (1999). Evolving role descriptions of the acute care nurse practitioner. Critical Care Nursing Quarterly, 21(4), Kleinpell, R.M., Faut-Callahan, M., Lauer, K., Kremer, M.J., Murphy, M., & Sperhac, A. (2002). Collaborative practice in advanced practice nursing in acute care. Critical Care Nurse Clinician in North America, 14, Knaus, M.L., Felten, S., Burton, S., Fobes, P., & Davis, K. (1997). The use of nurse practitioners in the acute care setting. Journal of Nursing Administration, 27(2),

7 References References McLaughlin, R. (2007). Preparation for negotiating scope of practice for acute care nurse practitioners. Journal of the American Academy of Nurse Practitioners, 19, doi: /j x National Council of Sate Boards of Nursing. APRN Model Act/Rules and Regulations. August,2008. Retrieved 2/26/10 from: National Panel for Acute Care Nurse Practitioner Competencies, (2004). Acute care nurse practitioner competencies. Washington, DC: National Organization of Nurse Practitioner Faculties. Retrieved from National Task Force on Quality Nurse Practitioner Education. (2002). Criteria for evaluation of nurse practitioner programs. Washington, DC. Retrieved from National Task Force on Quality Nurse Practitioner Education. (2008). Criteria for evaluation of nurse practitioner programs. Washington, DC: Author. Retrieved from O Neil, E.H. & The Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. San Francisco, CA: Pew Health Professions Commission. Percy, M.S. & Sperhac, A.M. (2007). State regulations for the pediatric nurse practitioner in acute care. Journal of Pediatric Health Care, 21(1), doi: /j.pedhc Pediatric Nursing Certification Board. (2010). Primary Care Comprehensive Program Review Application. Retrieved from Sorian, R. (2006). Measuring, reporting, and rewarding performance in health care. Commonwealth Fund/Alliance for Health Reform 2006: Washington, D.C: Bipartisan Congressional Health Policy Conference. Hawkins-Walsh, E., Berg, M., Beauchesne, M., Gaylord, N., Verger, J., & Osborn, K. (2011). Educational Guidelines for Combined Acute and Primary Care Pediatric Nurse Practitioner Programs, Journal National Council State Boards of Nursing, 1, (4). 7