Development of a Neonatal Nurse Practitioner/Physician Assistant Program for Clinical Coverage in a Newborn Intensive Care Unit Jo Ann Matory, MD FAAP Michael Stone Trautman, MD FAAP Edward Liechty, MD FAAP
Disclosure We have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial servicers discussed in this CME activity. We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.
Objectives Identify need and responsibilities necessary for NNPs and PAs who provide clinical coverage in NICU Discuss methodology necessary for establishment and maintenance of clinical managements and procedural skills Review essential aspects of coding and billing for NNP/PA services in NICU
IUSOM NNP/PA Clinical Program Provides clinical coverage for 7 NICUs in Indiana Section Director: Dave Ingram, MD Medical Director: Jo Ann Matory, MD NNP Director: Cheri Walkosak, NNP Coding and Compliance Director: Edward Liechty, MD Education Director: Michael Trautman, MD
IUSOM NNP/PA Program Development Identified need for increase in NNP/PA coverage July 2011 due to change in ACGME RRC duty hours Primary need in Riley NICU: 55 bed Level 3C unit; 611 admissions in 2011 Clinical service was provided by house staff and NNP/PA staffs, averaging 4 NNP/PAs daily Required increase to 6 NNP/PAs daily Major recruitment effort initiated
NNP/PA Program Goals Provide highest possible level of care for newborns in our unit Ensure continuity of care for infants following discharge Encourage development of individual professional career goals for each NNP/PA
NNP/PA Program Objectives Provide excellence in care and compliance with established standards in neonatal medicine Document appropriate follow up for all patients discharged from our units Provide support for academic, research and other educational interests for each NNP/PA Participate in outreach for referral units
NNP/PA Clinical Service in NICU Identification of need Purpose Strategic Plan Table of Organization developed Anticipated service model Establishment of support from medical staff Collaborative practice agreements Orientation Timeline Individualized Efficient scheduling Full time vs. part time; 24 hr. or partial day work hrs.
Strategic Plan for Program Development Recruitment Initial contact Interview process Offer/Acceptance Responsibilities Orientation Clinical role Competencies Programmatic Support Retention Competitive salary Support for education and professionalism Individualized career development
NNP/PA Table of Organization Department/Section Director Advisory Board NNP/PA Medical Director Coding & Compliance Director Education Director Business Manager Administrative Assistant NNP/PA Director Associate Director Liaisons Orientation Coordinator Program Dev. Subcommittee Education Outreach Nursing D/C Planning
TO-Administrative Committee Section Director Advisory Board Medical Director Administrative Assistant/Business Manager NNP Director/PA Director Associate Director Orientation Coordinator
Recruitment Initial contact: Recruiters, newspaper ads, nursing programs, NICUs, networking-conferences, perinatal organizations Interview process: Resume reviewed, phone on site, feedback from interviewer evaluations; references contacted Offer/Acceptance: Business manager input; applicant informed of decision by NNP/PA director
Responsibilities Orientation: Establish timeline to meet program needs Clinical role: Privileges requested credentialing Role of proctoring Collaborative Practice Agreement Competencies: Established and maintained Programmatic Expansion/Support: Investment from NNP/PA staff in conjunction with support services (nursing, respiratory, social service, pharmacy)
Orientation Timeline-Example Week 1: get started - Review checklist - Self-evaluation, develop plan for growth - Learn to pre-round; round and view neo-data PowerPoint presentation and attend Cerner class - Start progress journal - Attend educational opportunities whenever possible - Rotate through three teams over next three months Week 2-4: integrate - Develop ability to extract data from Cerner, Synapse - Gradually manage 4-6 patients with close supervision by preceptor. This includes preceptor looking up labs, fluids, & electrolytes/ any other tests & consults - Attend educational opportunities: meetings, simulations - Interface with other disciplines: pharmacy, dietary, charge nurse, resp. therapy, social work, family support, cardiology/cvs planning meeting, discharge rounds - Review feedback from faculty and preceptor along with a one month review with Dr. Matory, preceptor and Sandy. Weeks 4-8: develop - Gradually manage 6-8 patients with continued support from preceptor. The preceptor will continue to follow fluid and electrolytes and other diagnostic evaluations - Work on organizational skills (follow work pattern) - Continue to attend educational opportunities as able
Orientation Timeline-Example Continued Two month evaluation: - Review initial plan for growth - Review faculty and preceptor feedback - Identify remaining needs - Develop plan to complete orientation process Weeks 8-12: organize - Gradually manage 6-9 patients and up to 11 patients on weekends with resource person available at all times - Hone skills to interface with colleagues and organize care of complex patients - Complete competency record Three month evaluation: - Review goals from initial plan and completion of goals. - Review faculty and preceptor feedback - Review progress journal - Meet with Sandy, JoAnn, Casie, and Cheri to determine if all orientation goals have been met If the orientee is not prepared to complete orientation at the end of 3-6 months, an addendum to the orientation process will be planned. At the end of 6 months, review progress with Casie and Cheri; discuss possible University Hospital and Transport Orientation. Dec.2011/SLM
TO- Additional Members required for Expansion Program Development Subcommittee Liaisons Education Nursing Discharge Planning Outreach Additions as indicated with further expansion and/or identification of need (Transport, Research, etc.)
Retention Competitive salary Support for education and professionalism Academic, research, collaborative work, mentors, role models Individualized NNP expectations Educational projects, protected time JOB SATISFACTION!
Challenges! Staffing and scheduling patterns Varied levels of experience of staff Role models/mentors To teach or not to teach Office space Unit based conflicts Increasing national demand for NNPs/PAs
Michael Stone Trautman, MD FAAP
How To Educate
Competency in the Neonatology for NNPs and PAs Knowledge: Cognitive information to perform a task or procedure Assessment and interpretation of clinical information Skills: A specific procedure and the frequency of performing that procedure to be competent to perform A procedure frequency to maintain a skill Attitude: An understanding and positive attitude towards teamwork and patient safety
Curriculum for the NNPs and PAs Developed a series of self directed learning sessions, clinical skill simulations, and in situ simulations, by which the NNP/PA is asked to demonstrate certain skills but be able understand the whys and order a set of skills or procedures need to be performed.
Allows 24/7 access to information Self Directed Learning Allows learner to proceed at their own rate Disperses the educational opportunity throughout a larger system
Disadvantages of Self Directed Education Somewhat Impersonal To be effective, it has to have some form of accountability and the ability to tract the learner as to whether they have completed the assigned tasks.
Riley Hospital for Children Indiana University Health
Simulation Skills Sessions Once the NNP/PA has completed the online education, they participate in a skill session to demonstrate their ability to perform the skills. These are averaging on a quarterly basis with series of afternoon session which last 1-3 hours. Sessions are supervised with a neonatologist and simulation educator. Feedback is immediate and results noted.
In Situ and Simulation Sessions In situ simulations take place monthly in the NBICUs while simulation sessions occur quarterly. Sessions require an understanding of the patient s clinical condition and skill demonstration. The in situ simulations occur monthly basis and engaging both the NNP/PA, nursing staff and respiratory therapy. Simulation sessions are quarterly. Feedback with each format is an essential component of the educational experience
Edward Liechty, MD FAAP
Throughout CPT, Physician is being replace by Qualified Healthcare Provider National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). Each provider needs NPI to bill Medicare/Medicaid. Most Commercial payers also use NPI
Incident To Medicare has specific rules for physicians to bill for practitioner services Incident to the physician These only apply in the Out-patient setting Neonatologists cannot use Incident to Billing in the NICU
Nurse Practitioners Crucial Distinction Employed by Physician Group Able to use all documentation, procedures, etc. as contributing to the Global Code Able to bill independently for procedures, other services Employed by Hospital Cannot use Physical Exam or Assessment/Plan documentation as contributing to Global Code
How can NNPs bill Allowable Scope of Practice determined by state laws Considerable variation state to state Need to have hospital privileges with defined scope of practice Need to be an approved provider by the 3 rd party payer Can then bill for all services for which they hold privileges and are allowed under state laws
Should the charge be under physician or NNP NPI If the NNP did the work without direct supervision, he/she should bill under NNP NPI PICC lines, Delivery Attendance, prenatal consults If physician contributed substantially to the work Directed care then service should be billed under physician NPI Daily Global Critical/Intensive codes Newborn resuscitation IF physician was in the DR directing the care
Documentation As always this is key Physician should document clearly the work that she/he performed. Always use the term Direct Care or an equivalent Co-signs are not adequate I saw and evaluated this patient. I discussed all aspects of patient management with the NNP and agree with the findings and plan as documented in the NNP's note.
NNP Procedures and Transport If the NNP preforms a billable service it should be billed under NNP provider number unless directly supervised by neonatologist (at the bedside, delivery room) If the NNP does the transport, all transport codes should be under NNP number Neonatologist may not bill 99288 (transport phone supervision) if NNP bills for face-to-face service
PICC Lines CPT 36568 - Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age (CPT 2012 p 203) Work RVU 1.92 Total Facility RVU 2.86 Not bundled with Hourly CC, Transport, or Neonatal/Pediatric CC/Intensive Care codes
Summary It is important to identify specific needs for your individual newborn unit before establishment of program Coordination of NNP/PA clinical service must include consideration of administrative and nursing services Initiation of service must include individualized competency needs (establishment and maintenance) Accurate coding and billing must be established and monitored
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