10/7/2015. Outcomes. Supporting Nurse Practitioners: Quiz

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1 Supporting Nurse Practitioners: Rebecca-Maria Norwick, RN, FNP, DNP-S Anitha Mullangi, MD, FAAFP Keely Uhlir, NP, MSN, Pediatric NP Mary Ellen Wilkosz, RN, FNP, PhD Outcomes What are the challenges of hiring and retaining Nurse Practitioners? How can we use NP students for workforce development? What are ways that FQHCs can support novice nurse practitioners in their first year of practice? Quiz Which of these has not contributed to the deficit of primary care providers? The Affordable Care Act and expanded Medicaid. The aging baby boomers and aging workforce. A society that richly rewards and publically lauds primary care providers. 1

2 Who is doing the work? Three thousand nurse practitioners delivered 9.7 million visits or 11% of all community health center visits. (HRSA 2011) What is the work like? Flinter s 2012 study of new NPs found them faced with: A brief appointment for a chief complaint of bump on the leg that proved to be an aggressive cancer in an uninsured, migrant farm worker. 2

3 A new pediatric patient with a list of multiple co-morbidities and medications initiated elsewhere. The crashing diabetic, newly homeless and contemplating suicide. The first year of practice: novice nurse practitioners Desire for more structured and NP supported preceptors during clinical sessions. Lack of clinical support translated into high anxiety. Request for increased faculty support with challenging patients and discussion forums to discuss ethical decision making. 3

4 Request for blocked out clinic time to see specific population groups (ie prenatal, newborns) or develop skills (IUDs, x-ray). Uncomfortable with physician preceptors who are viewed as unapproachable or too busy. Olmeda and Brown 2012 The answer? Providing FNP Students with quality clinical experiences. Formal mentoring programs. FNP Residencies. History and Background Guided experience = preceptorship Goal = manage care with optimal health outcomes Preceptorship highly useful strategy for clinical education Education is individualized Create link with classroom knowledge and patient care Role modeling Pragmatic/Practice reality Webb, J., Lopez, R, & Guarino, A. (2015). Incentives and Barriers to Precepting NP Students. JNP, 11(8) p

5 Who Can Precept NP Students? NPs MDs DOs PAs CNMs Preceptors Students... So why is there a shortage of preceptors????? Preceptor Shortage is Multi-factorial IOM ACA demand = Enrollment Competition Preceptor Constraints Barriers to Precepting Rapid pace Productivity Limited time for teaching Multiple demands TEACHING IN CLINICAL SETTING Variable teaching/learning opportunities Limited time for feedback 5

6 Incentives For Precepting Credit toward recertification Giving back Open and accessible communication with school Enjoy teaching and being a preceptor Adjunct faculty status CEUs Ø Burns, C., Beauchesne, M. (2003). Mastering the Precepting Role: Challenges of Clinical Teaching. JPHC 20(3), Webb, et al 2015 Connection With Program Understand expectations of the program Regular communication between program and preceptor Clinical faculty site visit Student evaluation Participate in final grade decision Program Preceptor Lyon, D. & Peach, J. (2005) Primary Care Provider s View of Precepting NP Students. JANP, 13(5), Benefits of Having a Student Molding a student into the perfect fit for your office They add value Currency Extra attention for patients Fresh perspective Catherine Burns, PhD, RN, CPNP, FAAN, Michelle Beauchesne, DNSc, RN, CPNP, Patricia Ryan-Krause, MS, MSN, RN, PNP, Kathleen Sawin, DNS, CPNP, FAAN. J Pediatr Health Care. 2006;20(3): Retrieved 12/27/2014: 6

7 School s responsibilites Who can students precept with? MDs, DOs, NPs, PAs*, CNS, CNM How do students find preceptors? Clinical coordinator, word of mouth, prior students, friends, acquaintances Legal Contracts? Agency contract and/or LOA Do students carry liability? ABSOLUTELY! Certified Background Background check, drug test, immunizations, current licensure, CPR, TB, Things Agencies need to Consider Related to Student: Interview Immediate access to HER HIPAA/Orientation More independent = less supervision Include student in all aspects of visit Space issues weekends and evening clinics Things Agencies need to Consider Related to Preceptor: Incentivize Decrease patient load 7

8 FNP Residency Santa Rosa Community Health Centers Federally Qualified Health Center 2013: 41,041 people in our care 173,088 medical visits Family practice, homeless shelter, high school, pediatric sites. Flinter Model I. Intensive Orientation II. Gradual Assumption of Responsibilities III. Assigned Preceptors 1 year program, 3-4 every 6 months Full time with benefits, 80% of scale. I. Intensive Orientation Motivational Interviewing 4 Habits Cultural Competence Formularies and charitable programs. LARC: IUD, Nexplanon Implant Shadow other providers. 8

9 II. Gradual Assumption of Responsibilities 1 patient an hour to start, 9 in 4 hours by 11th month of program Labs and x-rays reviewed by faculty for 3 months Progress notes: all for 6 months, then select DEA at 6 months III. Assigned Preceptors Preceptors do not see patients when in clinic with FNP Residents (keep a panel). Core faculty: 2 FNPs including project director/clinical lead Family Medicine Physician w/ OB Internal Medicine physician Pediatrician Medical Director Outpatient Specialty Rotation Procedure Clinic (our physician): Simple skin surgery, endometrial biopsy Outside Specialists: GI, rheumatology, internal medicine, ophthalmology (fundal exam) 9

10 Recruiting Residencies are a hot item, we can pick and chose. FNP students 2-3 UC San Francisco, 1 local FNP Students from the local University: likely to want to stay in area Budget 3 FNP Residents to 1 Preceptor in clinic. Meaningful Use, QIP, Medical Home bonuses FNP Resident needs less nursing support. Project Director : 4-6 hours a week Administrative and scheduling support. Accreditation 1. American Nurses Credentialing Center practice transition accreditation program ($10,000) APGAP (Association of Post Graduate APRN Programs) - Carolinas Health Care System 3. National Nurse Practitioner Training Consortium -Margaret Flinter 10

11 Outcomes A delightful crew of bright, enthusiastic new nurse practitioners who join us every 6 months. 16 graduates, 22 total residents 13 working as FNPs in primary care settings 10 in FQHCs. 5 hired full time internally. 12 are ethnic minorities. FNP Residents are well versed in the chronic care model, attentive to routine health maintenance, and diligent about charting. Patient Access FNP Residents take more new patients a shift than other providers. Weekends, evenings, holidays. Vacation coverage. 11

12 A Note Physician Extenders? Full extent of their license just like RNs, PAs and MAs. IOM Report 2010 Full Scope of Practice for efficiency and productivity. Final Note on the FNP Residency. Improved Patient Access Improved Diversity and access to culturally competent providers. QIP and Meaningful Use goals. Recruiting and retaining skilled providers much easier. Thank you! Flinter, Margaret (2012). From new nurse practitioner to primary care provider: bridging the transition through FQHC-based residency training. Online Journal of Issues in Nursing. Jan2012, Vol. 17 Issue 1, p1-1. 1p. Sargent, L. & Olmedo, M. (2013). Meeting the needs of newgraduate nurse practitioners: a model to support transition. The journal of nursing administration. 43(11), pp

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