Tracy Klein, PhD, FNP, FAANP, FRE Former Advanced Practice Consultant Oregon State Board of Nursing 1
NP Type Acute 19 Total Adult 297 College Health 2 Family 623 Geriatric 36 Neonatal 21 Nurse Midwife 198 Pediatric 145 Psychiatric Mental Health 254 Women s Health 138 Total 1,733 (all except 58 with RX authority) NP Type Total Acute 44 Adult 337 College Health 0 Family 1,314 Geriatric 34 Neonatal 48 Nurse Midwife 281 Pediatric 144 Psychiatric Mental Health 433 Women s Health 110 Total 2,745 (all except 18 with RX authority) Oregon licenses an average of 84 new NPs a year Decreases seen in pediatrics, women s health, geriatric College health no longer licensed Adult health had slow growth at 11% over past 12 years Acute, family and neonatal doubled their numbers (131%, 128% and 110% increase in 12 years) Slow growth in rate of Nurse Midwives (29%) and Psych Mental Health (41%) despite in state programs may represent attrition 2
Boriskin& Klein circa 1999 The Board s first designated NP position was appointed (Mitch Boriskin, FNP) Tracy Klein WHCNP hired as Board s first designated APRN Consultant (Sept. 8, 1998) NP prescriptive authority became mandatory Division 52 was adopted recognizing CRNAs as APRNs NPs were able to prescribe Schedule III-V from a formulary approved by the Board after review by a committee of NPs representing each specialty Formulary committee members: Mitch Boriskin, Jane Harrison-Hohner, Kay Gage, Cathy Blosser, Susan Collins, Carol John and Traci Hoiting CNS were not regulated by the Board of Nursing beyond general RN licensure SB 948 rulemaking was completed which implemented Schedule II prescribing for NPs Chronic pain policies and regulations were developed and adopted to reflect the role of the NP in prescribing narcotics for chronic pain College dispensing rules were modified to permit NP dispensing of Plan B Initial rulemaking task force convened to develop CNS rules and regulations for APRN practice pursuant to the passage of HB 3000 in July 1999 The Board reviewed extensive legal analysis of federal and state law and concluded that Methadone could be prescribed for pain management only by Nurse Practitioners. Methadone was therefore added to the Nurse Practitioner formulary The Board sought and received opinion from the Center for Drug Evaluation and Research at the FDA that Mifiprexmust be prescribed (but not dispensed) by physicians only Division 54 adopted recognizing CNSs as a category of APRNs. Practicing CNSs were given until October 1, 2001 to present for licensure in order to use the title CNS Klein appointed to NCSBN APRN Special Committee to review and develop criteria for national certification exams for APRN licensure 3
Members of the formulary committee met 5 times yearly to review drugs for scope and standards and make recommendations to the Board. Committee members were: Mitch Boriskin, FNP Carol John, ANP Irene Vetto, ANP Mary Carpenter NMNP/FNP Kay Gage, PMHNP Sarah Duvall, PMHNP Susan Collins, NNP Teri Woo, PNP Traci Hoiting, ACNP A small task force was convened to help develop and write a complementary and non-prescriptive remedies policy clarifying the NP role and obligation in suggesting these remedies to their patients The Board publishes a booklet which is provided to applicants for prescriptive authority http://www.oregon.gov/osbn/pdfs/publications/pre scriptive_booklet.pdf NPs could now sign POLSTs SB 235 passed to authorize NPs to complete and sign death certificates. OSBN works with Vital Records department to develop processes, procedures and communications to NPs. SB 245 passed to allow NPs to prescribe home health services (later invalidated by federal regulatory guidance to state) HB 2627 allows NPs to transmit electronic prescriptions. HB 3919 authorizes medical use of marijuana (NPs may recommend but not authorize) 4
Nurse Practitioners authorized by SB 680 to authorize workers compensation and temporary disability with limitations: (C) Notwithstanding any other provision of this chapter, a nurse practitioner as defined in ORS 678.010 and practicing as licensed under ORS 678.375 to 678.390 is not subject to the provisions of subparagraphs (A) and (B) of this paragraph. Such nurse practitioner may provide compensable medical services and authorize the payment of temporary disability compensation for an injured worker subject to limitations applicable to an attending physician. Senators Harper and Fisher and Representative Kruse introduced SB 339 to abolish the Oregon State Board of Nursing. It was not successful. SB 708 removed emergency dispensing and provided for dispensing in non-rural areas of the state with Board authority for patients who meet specific financial and other criteria. Joint rulemaking instituted with Oregon Board of Pharmacy Division 50 was comprehensively rewritten from 2002-2003 to reflect changes in education, practice requirements, re-entry and continuing education. SB 460 added prescriptive authority to CNS scope of practice. Regulations adopted to add CNS prescribing to Division 56 of the Oregon Nurse Practice Act, including Schedule II-V authority. Pharmacists obtained the authority to administer vaccines The Portland Tribune initiated a series of investigatory articles focusing on the Board s Nurse Monitoring program and disciplinary process. An audit was initiated by the Department of Justice. Feb 14, 2006 Attorney General opinion received that survey and approval of AP programs in Oregon is a mandatory function of the Board 5
Board adopts the policy Utilization of Prescriptive Authority for Clinical Nurse Specialists and Nurse Practitioners to clarify how licensees can meet prescriptive authority practice requirements Board President Jim McDonald FNP is elected as first NP Board President June 29, 2007 Board moves to Tualatin office SB 717 seeks to establish a scope of practice committee under the Board of Medical Examiners. NPs testify against the bill which is ultimately defeated. August 29, 2007 OSBN Executive Director resigns APRN Consensus Model published July 7, 2008 Holly Mercer appointed January 2, 2008 as OSBN Executive Director SB 1062 abolished the NP formulary. Revised regulations adopted in 2009 retained federal prohibitions on prescribing methadone and retained requirements for FDA approval of drugs prescribed by NPs. Naturopaths gain expanded prescriptive authority Legislation developed and passed to create the Health Professional Services Program as an independently operated entity to monitor health professionals with drug and alcohol issues based on Board or self-referral and paid for by licensing fees. Regulations written and adopted for survey and approval of Nurse Practitioner programs in Oregon Mandatory furloughs instituted for all state employees 2009 Regulations added requirement for national certification for Nurse Practitioners licensed after January 1, 2011 Adoption of regulations and revision of policies related to prescribing off label, compounded, and grandfathered drugs Adoption of regulations regarding national certification criteria for NP licensure Klein reappointed to NCSBN APRN Advisory Committee Board survey of the University of Portland FNP/ DNP completed Clinical practicums in Oregon from out of state programs increase in volume and complexity Board develops registration process, outreach and education. Volume of placements necessitates creation of FTE assistant position dedicated to educational issues Survey completed of Oregon Health and Sciences University DNP/NP programs RN/LPN practice committee appointed 6
SB 136 authorizes CRNAs to prescribe with limitations of 10 day supply only meaning all APRNs in Oregon now have the potential to prescribe legend and controlled substances SB 8 removes geographic and financial restrictions for dispensing by NPs and CNSs SB 210 authorizes CRNAs to deliver services without medical collaboration in connection with procedures performed in outpatient settings Margaret Semple named interim executive director of OSBN for a two year term after a protracted public search September 10, 2013 Klein last day at OSBN Funding and support for education and preceptorships/residencies/fellowships Cross border practice/telehealth Scope of practice Leadership and Regulatory Capacity Unlicensed personnel Pain management IOM (1997) On Implementing a National Graduate Medical Education Trust Fund stated that "Nursing DME (direct medical education) should be structured like physician DME and be paid to sponsoring institutions for the support of advanced practice, graduate clinical trainees. This provision should be neutral with respect to the proportion of DME that has supported nursing; diploma, undergraduate nurse education support should be phased out in 4 years or less to allow present students to complete their training" Lewin-VHI (1995) Expanding the Capacity of Advanced Practice Nursing Education stated that: while some nursing schools needed additional faculty or bigger facilities to accommodate more students, the "single most significant factor" affecting a program's ability to expand is the availability of hospitals, HMOs, primary care clinics, and other facilities as sites for clinical instruction 7
There are approximately 115,000 physicians currently in residency programs. Federal support translates to about $100,000 per resident per year. Adding in state Medicaid payments, and considering the length of time that residents spend in training, the public investment per physician in training comes to half a million dollars or more (Dower, 2012) Average overall production rate of new primary care physicians using GME funding was 25.2% from 2006-2008. 4.8% practiced in rural areas ( Chen, Petterson, Phillips et al, 2012) Senators Wyden and Merkleysigned and circulated a Dear Colleague letter requesting a $251 million for the Nursing Workforce Development programs in FY 2014 FY 2014 federal budget increases funding for advanced nursing education 39.25% to a total of 23.256 million The Graduate Nurse Education Demonstration was mandated by Section 5509 of the Affordable Care Act and awarded by CMS to 5 hospital affiliated programs: Duke, Rush, Scottsdale Healthcare Medical Center, U Penn and Memorial Hermann Texas We are approaching a crisis in both the cost of clinical education and the insufficient supply of suitable clinical sites if we continue to use traditional approaches to clinical education. Teaching technologies, including simulation and technology for distance delivery, will also continue to be important as we discern best practices for technology use in nursing education. (Tanner, 2012,p. 419) Practice of registered nursing means the application of knowledge drawn from broad in-depth education in the social and physical sciences in assessing, planning, ordering, giving, delegating, teaching and supervising care which promotes the person s optimum health and independence. (ORS 678.010) OSBN Nursing Practice Committee has been charged with developing a background paper to review with the Board NPs continue to have concerns regarding cross border practice, especially with RXs NPs are currently providing virtual services which meet Board regulations if they provide valid assessment and meet HIPAA requirements 8
Recognizing that the issues of licensure and the delivery of telehealthservices were evolving and becoming more complex, the U.S. Congress passed the Health Care Safety Net Amendments of 2002, Public Law (P.L.) 107-251. Section 102 authorized the award of incentive grants to state professional licensing boards to promote cooperation and encourage development and implementation of state policies that will reduce statutory and regulatory barriers to telehealth. In response, National Council of State Boards of Nursing developed the Nurse Licensure Compact (adopted by 22 states) NURSYS provides a database to share licensure actions from state to state APRN compact passed by Iowa, Texas, Utah and Idaho(?) Federation of State Medical Boards has a uniform application for licensure 10 state boards of medicine issue a telemedicine license for practice across state lines (including Oregon) Many states (including Oregon) mandate coverage for telehealth services: A health benefit plan must provide coverage of a telemedicine health service if the plan provides coverage of the health service when provided in person by the health professional, the health service is medically necessary and the health service does not duplicate or supplant a health service that is available to the patient in person. OR. REV. STAT. ANN. 743A.058(2). 9
Other possible models include: Consulting exceptions Expedited endorsement Reciprocity Mutual recognition (NLC) Registration Limited License National License Federal License Areas of conflict and confusion continue to be: Can FNPs practice in hospital/acute settings? Can FNPs do psychiatric mental health services and if so, to what extent? Ancillary Factors include: Geography Medical staff and credentialing Consensus model adoption State practice acts and policies Grandfathering Training opportunities 10
NONPF (2013). Primary care and acute care certified nurse practitioners. Available at: http://www.nonpf.com/associations/10789/file s/acpcnpstatementfinal2013.pdf NONPF (2013). Population focused NP competencies. Available at: http://www.nonpf.org/associations/10789/files /PopulationFocusNPComps2013.pdf AACN (2012). Scope and standards for acute care NPs. Available at: http://www.aacn.org/wd/practice/docs/acnpscope-and-standards.pdf Multiple legislative efforts nationally from 1998-2013 to consolidate licensing Boards and functions Murphy (2011) Elimination and Consolidation of State Entities available at: http://www.ncsl.org/documents/fiscal/eliminations20 11.pdf Since 2009, at least 19 states have eliminated or consolidated state entities. Of these states, at least 11 have instituted eliminations and 13 have implemented consolidations. Several states California, Connecticut, Missouri, Nevada and Washington have done both. Bonelli (2003) Health Licensing Boards and Governance Structure: No consensus on relationship between state regulatory models and criteria for effectiveness No uniform best practices for regulatory Boards OSBN Revenues 100 % Other Funds Licensing Fees paid by nurses (RNs, LPNs, Advance Practice Licenses, CNAs) Fines and penalties Fees for fingerprinting new applicant licensees Transfer of funds from Department of Human Services (Medicare and Medicaid grants) 11
Staff Consultant/Executive positions open 9 or more months in 2011-2013 Executive Director RN/LPN Consultant? APRN Consultant Emergence of CCOs in Oregon and changing health care models bring multiple questions regarding role of RNs/APRNs with relationship to: Medical assistants Health navigators Community healthworkers Peer Wellness Specialists Peer Support Specialists Techs hired in multiple positions EMTs Washington state adopted House Bill 2876 in 2010 pursuant to multiple complaints regarding a nurse practitioner owned clinic First state to identify a maximum prescribing threshold of 120 Morphine Equivalent Dose (MED) above which consultation is generally required Pain regulations apply to a wide range of health care providers: Physicians Physician Assistants Osteopathic Physicians Osteopathic Physician Assistants Advanced Registered Nurse Practitioners Dentists Podiatric Physicians Details at: http://www.doh.wa.gov/publichealthandhealthcareproviders/healthcareprofessio nsandfacilities/painmanagement/frequentlyaskedquestionsforpractitioners.aspx 12
Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has. Margaret Mead, American anthropologist 13