DiversityNursing Blog

By Heather Stringer

When Carrie Bilicki, RN, MSN, ACNS-BC, OCN, met a 60-year-old patient who had been diagnosed with aggressive endometrial cancer, she began to have a persistent — albeit unconventional — idea. 

Bilicki, a cancer nurse navigator in Wisconsin at the time, recently had attended a lecture about a progressive treatment for this type of cancer that involved using a chemotherapy drug traditionally prescribed for ovarian cancer. The patient’s cancer had spread to nearby organs, and she had a poor prognosis. Bilicki convinced the physicians to try the alternative medication. Unfortunately, the patient faced another serious hurdle: The insurance company would not cover the cost of the medication because it was not the standard treatment. At that point, the woman seemed to face the unenviable choice between cancer treatment and financial ruin.

Although patients and providers would like to hope this type of extreme dilemma is the exception, the case may be representative of the near future for two reasons. First, as a 60-year-old, the woman was a baby boomer, and researchers predict the incidence of cancer will increase dramatically as this large segment of the population ages. According to a study published in the Journal of Clinical Oncology in 2009, the U.S. can expect a 67% increase in cancer incidence among older adults between 2010 and 2030. 

Second, statistics suggest cancer treatment is becoming increasingly unaffordable, even for those with insurance who struggle to afford steep copayments. For example, The US Oncology Network — a national group of about 1,000 oncology physicians who treat more than 750,000 cancer patients per year — reported about half of the patients covered by a Medicare Part D plan have required copay assistance for oral chemotherapy for the past several years.

“My message to my peers is to know the financial resources available because there are hundreds of them,” Bilicki, who now is a clinical nurse specialist in breast services at Froedtert Center for Diagnostic Imaging in Milwaukee, Wis., said. “There are foundations, specialty organizations and websites that tell us where to get help. If a patient does not have an advocate to link them to that resource, they will never know it is available.” 

What's new?

For many patients, the desire to find a way to afford medication is driven not only by the fact that they have cancer, but also because the treatment options available today have increased the odds of survival. 

“By far one of the biggest advancements is more personalized medicine that targets cancer cells rather than traditional chemotherapy that did not differentiate between good and bad cells,” Kim George, RN, MSN, ACNS-BC, OCN, a cancer program consultant from Wichita Falls, Texas, said. “For example, now we can test biopsy tissue for specific tumor antigens and biomarkers and then prescribe treatments that target those antigens.” 

The advancements in cancer treatment also are reflected in improved survival rates. According to the Surveillance Epidemiology and End Results Cancer Statistics Review 1975-2009, for example, the 5-year survival rate for breast cancer among women in the U.S. between 1975 and 1977 was 75%. Between 2002 and 2008 that number jumped to 90%. During the same time periods, the 5-year survival rate for both men and women with colon cancer has increased from 50% to 65%. 

“Another major advancement has been the increase in availability of oral chemotherapy and biotherapy,” George said. “It has shifted the care setting. Years ago, the majority of cancer patients received IV infusions, and now more patients can take their medication orally at home. It is wonderful for convenience, and it is also less painful.” 

However, George said, reimbursement is not always a given with oral chemotherapy. “A lot of oncology medications are given off-label, which means that the FDA has not approved a drug for a specific diagnosis, so it may not be covered by some insurance policies,” she said. 

Point the way

The art of navigating the path to financial assistance for cancer medication is not simple, and organizations such as The US Oncology Network, based in The Woodlands, Texas, have hired professionals to help patients connect with funding resources and launched the OncologyRx Care Advantage pharmacy in 2006. Nurses in the network can refer patients to Care Advantage staff who help them apply for financial assistance. 

“The types of drugs used to treat cancer today are definitely more expensive than when I started working in oncology almost 30 years ago,” said Lori Lindsey, RN, MSN, NP, OCN, a clinical services program manager with The US Oncology Network. “Multidrug regimens, including oral targeted therapies, can sometimes cost $30,000 for a round of treatment, although the use of these drugs has markedly improved outcomes and increased survival for some diseases.” 

For patients who are uninsured, the best option is to apply directly to the drug manufacturer for patient assistance, said Meg Asher, a patient access coordinator/patient advocate lead at the Care Advantage pharmacy. “When we learn that a patient is without insurance, we notify the doctor’s office and send a manufacturer’s application to them for the patient’s use,” Asher said. “Under these circumstances, we will not be the dispensing pharmacy; the manufacturer has their own specified pharmacy that will service the patient.”

Even those who are insured under Medicare Part D often require assistance because the copayments can be thousands of dollars, Asher said. For these patients, the Care Advantage advocate team helps patients connect with various foundations that provide copay assistance in the form of grants. Some of the foundations assist patients who suffer from a specific disease, while others help those who are taking a specific drug for a disease. 

While some facilities have staff trained to help patients find financial assistance, this is not always the case. For these patients, one resource is the Patient Advocate Foundation, a nonprofit organization with case managers who help patients with life-threatening illnesses to maintain financial stability. 

“When I was a hospital nurse, I honestly didn’t know about a lot of the resources available to help patients after they left my care,” Pat Jolley, RN, the clinical director of research and reporting at PAF, said. “Many people have never had to ask for financial help in the past, and they are unaware that there are options. If they are newly diagnosed, we try to educate them about the likely expenses down the road to help identify potential problems. In my experience, when patients contact us saying they cannot afford one thing, it is usually just the tip of the iceberg.” 

For example, PAF assisted a 62-year-old woman with breast cancer who was insured, but she was having difficulty scheduling her needed mastectomy because of outstanding medical bills. She was living on Social Security disability payments, and her insurance did not cover surgeries, scans or tests. The woman received a bill for $50,000 that included the cost of previous care and several office visits. By negotiating with the hospital and the providers, the PAF case manager was able to reduce the bill to a total of $950 and also facilitate the scheduling of her mastectomy. 

Suffering in silence

For Bilicki, one of her personal goals is to encourage patients to consider the financial aspect of their cancer care before they decide to pursue a particular form of treatment. 
“Nobody wants to talk about their financial state, and I think far too often patients suffer in silence rather than saying that they are having trouble with copayments, so what I do is proactively tell them about some of the resources,” Bilicki said. “Just because they have insurance does not mean they will have resources to afford the costs, so I empower all patients right off the bat to proactively seek out assistance if they need it.”

After patients have been diagnosed with cancer, Bilicki encourages them to learn about the resources at the American Cancer Society, which has patient navigators trained to help people connect with financial resources. She also tells them about a group called Patient Resource LLC, which has a website and a patient magazine that includes national, state and local resources available for financial assistance. 
In the case of the woman with endometrial cancer who could not afford a medication that was not covered by her insurance, Bilicki helped her apply for the drug manufacturer’s patient assistance program. Based on her income and medical necessity, she qualified for full assistance. She was on the medication for 15 months, and, despite her initial grim prognosis, the cancer has been in remission for the past five years. 

“I can always remember the tears and fear in their eyes when I first meet patients, and each time it feels like I’ve won the lottery when I help them secure the treatment they need, and they start smiling again,” Bilicki said. “Part of my big mission for my colleagues is to advocate for these patients so they do not miss out on options that can change their lives.” 

A little help can mean a lot

Point the way for patients who need assistance financing cancer treatments, by seeking resources such as the following:

• PatientAdvocate.org — Provides sources for copay assistance and answers questions about disability and insurance processes
• PatientResource.com — Features information on different types of cancer, newsletters and financial and advocacy resources
• CureToday.com — Provides an extensive list of national resources for advocacy, financial and pharmaceutical assistance
• RxOutreach.org — A nonprofit organization that helps low-income families who cannot afford the medication they need 
• CDFund.org — Chronic Disease Fund — A nonprofit organization that helps patients obtain lifesaving medications
For a list of drug assistance programs from pharmaceutical companies, visit Cancersupportivecare.com/drug_assistance.html.

Source: Nurse.com

by David Tennebaum

The single-use timer that will wholesale for about a dollar is designed to make a nurse’s life easier.In medicine, time isn't just money: it can mean the difference between life and death. Clot-busters must be given in the first hour of arrival in a hectic emergency room. Intravenous medications can spoil, and catheters that overstay their welcome invite infection.

By Susan Chapman and Bethany J. Phoenix

Because the Affordable Care Act requires that individual and small-group plans include coverage for mental health care that is comparable to that for general medical care, many analysts expect the demand for mental health services to dramatically increase over the next few years. In California, finding enough mental health providers to meet the demand will be a challenge, as the federal Health Resources and Services Administration has identified 128 Mental Health Professional Shortage Areas in our state.

After documenting vacancy rates for mental health professionals in county-operated mental health programs and state hospitals, the California Mental Health Planning Council suggested that one way to address this shortage is to increase the recruitment and preparation of psychiatric/mental health nurse practitioners (PMHNPs) as primary mental health providers. Given the direction of health care service delivery in the US, perhaps the most important advantage PMHNPs offer is that they are educated in an integrative practice model that stresses connections between physical and mental health and emphasizes health promotion. This is especially critical in public mental health settings, where many patients struggle to get to any health care appointment, much less multiple appointments with multiple providers.

Using PMHNPs to address shortages and increase access to care in public mental health settings, however, faces a number of challenges. To help understand and address these challenges, we are collaborating with the California Institute for Mental Health (CiMH) to conduct a Robert Wood Johnson Foundation-funded study that will include case studies in five California counties with a history of using PMHNPs. The aim is to document best practices, identify unnecessary restrictions on NP practice and formulate strategies to remove these restrictions. By the conclusion of the study in 2015, we hope to have evidence-based information for key stakeholders – from public mental health care systems to state policymakers – about how PMHNPs can help increase access to mental health services in the state.

One thing the study will allow us to do is examine in more detail presumed barriers that have emerged both anecdotally and from prior research. To begin with, just as with primary care, there is a need to rapidly fill the pipeline by incentivizing existing and future students to work in public mental health. That’s why beginning in 2009, California’s Mental Health Services Act began funding educational stipends to PMHNP students at three schools of nursing, including UC San Francisco. The stipend requires that students “pay back” their stipend by working in a public mental health setting for the equivalent of a year of service for each year of stipend funding.

That’s a fine start, but many of our colleagues across the state are concerned that scope-of-practice laws and the lack of good practice models for PMHNPs in California appear to undermine the effort to prime the pipeline.

For example, UCSF School of Nursing faculty member Aaron Miller was educated in Oregon and says that the biggest difference between the two states is that, “In Oregon, NPs can practice without a collaborative agreement with a physician…and the scope-of-practice law in Oregon contains an explicit description of the NP’s scope of practice: assessment, diagnosis, creation of plan and treatment.” By contrast, he says, in California NPs must always have a collaborative agreement in place with a supervising physician, and in every setting they have to devise agreed-upon standardized procedures that define what the NP can do – essentially, the scope of practice. Moreover, at present, practice models in the state do not facilitate optimal billing for PMHNP services.

Ebony Anderson, one of our former stipend students, says these limitations have dampened her willingness to strike out into independent practice as a psychiatric mental health nurse practitioner.

Thus, even as many in the state recognize that NPs can provide high-quality care and organizations are starting to utilize NPs’ full scope of practice, a number of factors may be erecting unnecessary obstacles to meeting the mental health needs of many Californians – especially in areas already short on qualified providers. These factors include reimbursement challenges, the effort involved in defining acceptable scope for each setting and finding physicians willing to provide NPs with the mandated level of supervision – and bill for services under their provider numbers, if appropriate.

Our charge, among other things, is to examine how and to what degree these factors affect the state’s ability to meet expected growth in demand for mental health services. Such research is the lifeblood of policy change. Our hope is that the results of our work will enable the state to fully leverage an educational system that is training PMHNPs to deliver outstanding care but, at least at the moment, sending them into a health care system that is not yet taking full advantage of their strengths.

Susan Chapman and Bethany J. Phoenix are leading a study to examine the structural, practice and policy opportunities and barriers that affect psychiatric/mental health nurse practitioners’ ability to most effectively use their skills and expertise in public mental health settings. Chapman directs the Health Policy Nursing specialty in the Department of Social and Behavioral Sciences at UC San Francisco School of Nursing. Phoenix is vice chair of the School’sDepartment of Community Health Systems and coordinates the School’s Psychiatric/Mental Health Nursing specialty. The study is supported by the Robert Wood Johnson Foundation’s Future of Nursing National Research Agenda, which is coordinated by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation.

Source: Science of Caring

To mark National Nurses Week, we asked new RNs about what every nurse needs to succeed. Five nurses from the DC/Maryland/Virginia region, all with two years or less of experience, answered the following question: What qualities or characteristics are most important to possess as a nurse, and why? 

Hannah Hanscom, RN, BSN, CPN, clinical nurse, surgical care unit, Children’s National Health System, Washington, D.C.

As a pediatric nurse, I believe there is no one quality or characteristic that is most important to being a nurse. Nurses must be passionate about caring for children and their families and be able to think critically and on their feet. But we also must be able to communicate effectively and efficiently with the family, patient and interdisciplinary team. We must be compassionate and able to stay calm when escalating care is needed. Although there is no one quality or characteristic that is most important for nursing, having a passion for the field, for caring for those in need, for educating others and for continuing your own education ties all the other qualities together. Nursing is not just a job or a career. Being a pediatric nurse is in many ways a calling; it is something that comes from the heart and is a lifestyle you must be passionate about. 

Shannon Levin, RN, med/surg unit, Novant Health Haymarket Medical Center, Gainesville, Va.

Nursing is more complex than ever. Nurses are managing new technologies, constant advances in best practices and more and more patients with multiple morbidities. Nurses must be organized multitaskers, with quick critical thinking skills. But a nurse who possesses empathy for his or her patients is the best kind of nurse. Nurses with genuine empathy understand that we often see patients and their families at one of the most difficult times. Most of our patients are experiencing some level of physical and emotional pain and often feel anxious and fearful about their hospitalization. An empathic nurse cares enough to identify and understand his or her patient’s feelings. The nurse listens to his or her patient’s medical history and current symptoms and eases his or her fear by explaining the need for hospitalization, the plan of care and ordered procedures. These actions help build trust and ultimately are the foundation of a successful nurse-patient bond and remarkable care. 

Rachel Nugent, RN, emergency department, Carroll Hospital Center, Westminster, Md.

It takes many characteristics to be a nurse. I believe the most important characteristics to possess are empathy, compassion, hope, patience and good communication skills. Being empathetic for patients and also for their families shows true compassion. Nurses must give patients a sense of hope when they may be at the lowest point in their lives. Nurses smile, and with that smile, a positive perception is given to patients and their families. Patience with not only yourself, but with patients, family members, doctors and coworkers is a must. Nurses must know when to speak up for themselves or their patients and when to intervene - especially when they suspect something may be wrong. Nurses advocate for their patients when they are in dire need. And, finally, one of the most important parts of communication is that nurses must always be great listeners, even after a long 12 hour shift. 

Brooke Schautz, RN, emergency department, MedStar Harbor Hospital, Baltimore

By Eric Swensen

While 12-hour weekend shifts for nurses are typical, it’s not common to do it while also attending medical school full-time. But that’s what Mazvita Ethel Simoyi did during her first year at the University of Virginia School of Medicine, commuting every weekend to a hospital in Washington, D.C. to help pay for her education.

Now set to earn her M.D. degree from UVA this month, Simoyi laughed when asked how she endured the relentless schedule of work, schoolwork and commuting.

“I honestly do not know how I did it,” she said. “Necessity makes you rise to the occasion.”

Working Toward a Lifelong Dream

Simoyi knew she wanted to be a doctor from the time she was 5 or 6, when her father, Dr. Mike Simoyi, a general practitioner in Zimbabwe, brought her to his clinic to observe a tubal ligation. “I stood on a stool in the operating room, looking at him make the incision,” she said.

As she got older, she helped direct patients at the clinic where her father worked with her mother Regina, a nurse. The time she spent there deepened her commitment to medicine.

“The patients [at my parents’ clinic] are very, very grateful for the help they receive,” she said. “My father is also very involved in public health, and educating people at a time when HIV and AIDS was beginning to get a lot of attention. That’s why I wanted to be a doctor – so I could help people and share my knowledge with them.”

To continue her path toward becoming a doctor, Simoyi came to the U.S. from Zimbabwe at age 17 to attend college. After beginning as a biology/pre-med major at Butler University, she transferred to Howard University in Washington, D.C., earning a nursing degree in 2007. She went into nursing so she could earn a living while taking the remaining pre-requisite classes for medical school and “ensure that medicine was 100 percent what I wanted to do.”

After three years working as a nurse, she entered UVA’s School of Medicine in 2010. But she wasn’t quite done with nursing.

Full-Time Medical Student, Part-Time Nurse

During her first year as a med student, Simoyi worked weekends on a medical/surgical/oncology inpatient unit at Providence Hospital in Washington, D.C. She would leave Charlottesville around 5 p.m. Thursday or Friday for Washington, staying with her sister Nyasha or friends from Howard University when she wasn’t at work. She would return to Charlottesville around midnight Sunday to get some sleep before waking up at 7 a.m. Monday to begin another week of med school classes.

During her second year as a medical student, she worked part-time in Charlottesville as a hospice nurse. She continued working as a nurse until November 2012, when she was no longer able to work weekends due to her medical school clerkship.

“Time management was what really saved me,” she said.

Her commitment both to her education and her jobs impressed her classmates and faculty. “I was blown away by her work ethic,” said Chad Lane, a member of her medical school class.

As a part-time pharmacist during his time in medical school, Simoyi’s residency adviser, Dr. Shawn Pelletier, knows firsthand how tough her balancing act was. “It’s a lot of work,” he said. “While other people are studying or relaxing, you’re spending time working to pay tuition.”

The intelligent way Simoyi approached her dual responsibilities helped her do both successfully, said her adviser, Dr. Christine Peterson. “She knew exactly what she wanted to do. She’s very grounded and very realistic,” Peterson said. “She found nursing jobs that would mesh with the enormous amount of hours required for her studies.”

Simoyi also believes the extra hours she put in as a nurse helped with her medical school class work. “When I was reading information from a textbook, I could translate it to my patients. It helped solidify the concepts because I could apply it right away instead of waiting two years [to begin my clerkship],” she said.

When Simoyi did a four-week rotation in transplant surgery with Pelletier, he saw that “she already had the textbook answers, had digested that and had moved onto the next step.” In some cases, the only reply Pelletier had to her questions was: “That’s a good question – we’re trying to figure out the answer to that.”

While her nursing work left her less time to spend outside of class with her fellow students, Simoyi said she very much enjoyed her time at UVA. Her classmates were very welcoming and inclusive, and she appreciated that she was part of a large group of students who had taken non-traditional journeys to medical school.

“I was happy to see how many people had taken different paths, like IT and working as financial advisers,” she said.

Giving Back to Zimbabwe

This summer, Simoyi will begin a surgical residency at Baystate Medical Center in Springfield, Massachusetts. She chose surgery because she likes to work with her hands, figure out what’s wrong with a patient and quickly see results.

“You fix an artery, and you get to see the effects of your work immediately,” she said.

While she’s not sure whether she will end up practicing medicine in the U.S. or Zimbabwe, Simoyi definitely wants to give back to Zimbabwe. “I want to have some impact in Zimbabwe, even if I’m not there physically. I want to do something to make health care better, either in education or through standards of care for patients.”

Her classmates and teacher believe she is primed to succeed in whatever challenge she takes on next.

“Surgery is physically demanding and it requires mental toughness,” classmate Pranay Sinha said. “You have to be tough to go through what she has gone through.”

Source: University of Virigina Health System

© 2014 Travel Nurse Source

Source: Digital Journal

National Nurses Week traditionally is a time to recognize the crucial contributions registered nurses (RN) make to individuals' health and the U.S. health care system; this year, it's also a time to sound a note of urgency about the future, as projections signal the need to fill about 1.1 million RN jobs by 2022.

The 2014 National Nurses Week theme is "Nurses: Leading the Way," emphasizing nurses' roles in improving the quality of health care; participating as key members of collaborative, performance-based health care teams; and continually advocating to ensure patients remain the focal point of health care. National Nurses Week takes place May 6-12, ending on the birthday of Florence Nightingale, the founder of modern nursing.

"All nurses are leaders, whether they are in direct patient care, administrative roles, or meeting consumers' needs in new roles such as care coordinators or wellness coaches," said ANA President Karen A. Daley, PhD, RN, FAAN. "This week, we acknowledge nurses' vast contributions, as well as the need to develop the nursing workforce to meet our growing needs and improve the health of the nation."

As nurses assume more leadership roles in a system that is transforming its focus to emphasize primary care, prevention, wellness, chronic disease management, and coordination of care, a confluence of factors is driving the need for a huge increase in the number of RNs. About 11 million individuals have gained better access to health care through private health insurance marketplaces and the expansion of Medicaid under the Affordable Care Act; Baby Boomers are projected to swell Medicare rolls by 50 percent by 2025; and 53 percent of nurses are over age 50 and nearing retirement, according to a National Council of State Boards of Nursing survey.

The U.S. Bureau of Labor Statistics projects 1.1 million jobs for nurses between 2012 and 2022 – more than 500,000 each for newly created jobs and replacements for retiring nurses. Registered nurse is ranked second in projected new job growth among all occupations from 2012 to 2022, with 527,000 new jobs, according to the Bureau of Labor Statistics. To achieve that level of growth, ANA recommends four actions: 

• Increase funding for federal Nursing Workforce Development Programs (known as Title VIII of the Public Health Service Act, which marks its 50th anniversary this year). Funding generally has stayed level in recent years for these programs that assist in educating, training, and placing new nurses in areas of need.
• Recruit more nursing professors and increase incentives. Nursing faculty salaries generally are lower than what many faculty members could earn in clinical practice (an average of $68,640 compared to more than $91,000 for nurse practitioners). Many nursing professors also are nearing retirement age – nearly 3 of 4 are over age 50 – and will need to be replaced.
• Ensure an adequate number of clinical training sites so nursing students can fulfill educational requirements.
• Encourage hospitals and other employers to hire new nursing graduates now to benefit from mentoring from experienced RNs, and to mitigate the impact of the projected exodus of seasoned RNs in the coming years.

Read the full story at http://www.prweb.com/releases/2014/05/prweb11820230.htm