DiversityNursing Blog

Guest column: Nurses can ease crisis

Posted by Alycia Sullivan

Mon, Aug 05, 2013 @ 01:07 PM

Consider how long you may be in the waiting room for a visit for your child and consider how long it will take to get an appointment. The average wait time in an emergency room in 2011 was 64.3 minutes. Some experts expect that to double soon, especially in rural areas. Why? Because folks who cannot access primary care use the emergency room for primary care.

We are in a state of crisis. We need to serve more people with fewer physicians. The American Medical Colleges Center for Workforce states that there will be a national shortage of about 63,000 primary care physicians by 2015. South Carolina already ranks 33rd for lowest ratio of those physicians.

According to a 2012 article in Medical Care magazine, the number of nurse practitioners in the U.S. will increase by 94 percent by 2015. We have 2,592 Advanced Practice Registered Nurses (APRNs) already in South Carolina. Among these APRNs are Nurse Practitioners (NPs) and Certified Nurse Midwives (CNMs), who hold at least a master’s degree in nursing with advanced education and clinical training to assess, diagnose and manage a patient’s health care at the primary care entry while working collaboratively in teams for the optimal patient outcome. Allowing a patient the option to select an APRN as their primary provider could give people access to over 3,000 additional primary care providers when this crisis hits.

The problem deepens for the patients who will desperately need access to care. Currently, the barriers to practice for these advanced level nurses include: the inability for APRNs to order handicapped placards, the inability to order durable medical equipment, inability to refer patients for diagnostic care, limitations on prescribing certain medications for pain and more. An APRN cannot provide care for a patient or prescribe any medication for them unless they have permission and the “supervision” of a physician within a 45 mile radius. This archaic constraint means that patients struggle to get the care they need in a timely and safe manner.

In a rural setting, accessing care is even more burdensome for patients because of fewer providers and transportation options and higher unemployment, affecting health insurance eligibility. Accessing care is difficult and barriers exist everywhere.

The Institute of Medicine in their 2010 report, “The Future of Nursing,” calls for the removal of barriers for APRNs so access to primary care is improved. According to the Washington Post, about 6,000 APRNs have already opened independent practices. Nineteen states have already removed barriers and now allow APRNs to practice to the fullest extent of their education and training. There is no longer an excuse for South Carolina to have an “F” in the healthcare rankings.

We hope our policy leaders will take action and allow our qualified APRNs to provide the care that so many South Carolinians need before the burden on our healthcare system becomes even greater. Research shows that APRNs deliver safe, cost-effective, high quality autonomous care to manage a patient or population’s health, while working collaboratively in teams for the optimal outcome.

Source: Greenville Online

Topics: APRN, lacking, nurse practitioner, care, reform

The Gulf Between Doctors and Nurse Practitioners

Posted by Alycia Sullivan

Mon, Jul 01, 2013 @ 01:42 PM

describe the image

Not long ago, I attended a meeting on the future of primary care. Most of the physicians in the room knew one another, so the discussion, while serious, remained relaxed.

Toward the end of the hour, one of the physicians who had been mostly silent cleared his throat and raised his hand to speak. The other physicians smiled in acknowledgment as their colleague stood up.

“Nurse practitioners,” he said. “Maybe we need more nurse practitioners in primary care.”

Smiles faded, faces froze and the room fell silent. An outraged doctor, the color in his face rising, stood to bellow at his impertinent colleague. Others joined the fray and side arguments erupted in the back of the room. A couple of people raised their hands to try to bring the meeting back to order, but it was too late.

The physician had mentioned the unmentionable.

I remembered the discord and chaos of that meeting when I read a recent study in The New England Journal of Medicine of nurses’ and physicians’ opinions about primary care providers.

For several years now, health care experts have been issuing warnings about an impending severe shortfall of primary care physicians. Policy makers have suggested that nurse practitioners, nurses who have completed graduate-level studies and up to 700 additional hours of supervised clinical work, could fill the gap.

Already, many of these advanced-practice nurses work as their patients’ principal provider. They make diagnoses, prescribe medications and order and perform diagnostic tests. And since they are reimbursed less than physicians, policy makers are quick to point out, increasing the number of nurse practitioners could lower health care costs.

If only it were that easy.

Three years ago, a national panel of experts recommended that nurses be able to practice “to the full extent of their education and training,” leading medical teams and practices, admitting patients to hospitals and being paid at the same rate as physicians for the same work. But physician organizations opposed many of the specific suggestions, citing a lack of data or well-designed studies to support the recommendations.

In an effort to build consensus, the Robert Wood Johnson Foundation then invited a dozen leaders from national physician and nursing groups to discuss their differences. The hope was that face-to-face discussions would help physicians and nurses understand one another better and see beyond the highly charged and emotional rhetoric. The approach worked, at least initially; after three meetings, the group drafted a report filled with suggestions for reconciling many of the differences.

But an early confidential draft was leaked to the American Medical Association, a group that had not been invited to participate, and the A.M.A. immediately expressed its opposition to the report. Soon after, three of the participating medical organizations — the American Academy of Family Physicians, the American Osteopathic Association and the American Academy of Pediatrics — withdrew their support, and the effort to bring physicians and nurse practitioners together and complete the report collapsed.

Nonetheless, many health care experts remained confident, believing that the large professional organizations had grown out of touch with grass-roots-level health care providers. The guilds might oppose one another, but every day in medical practices, clinics and hospitals across the country, physicians and nurse practitioners were working side by side without bickering. Surely, the experts reasoned, providers who knew and liked one another would be receptive to trying new ways of working together.


Analyzing questionnaires completed by almost 1,000 physicians and nurse practitioners, researchers did find that almost all of the doctors and nurses believed that nurse practitioners should be able to practice to the full extent of their training and that their inclusion in primary care would improve the timeliness of and access to care.

But the agreement ended there. Nurse practitioners believed that they could lead primary care practices and admit patients to a hospital and that they deserved to earn the same amount as doctors for the same work. The physicians disagreed. Many of the doctors said that they provided higher-quality care than their nursing counterparts and that increasing the number of nurse practitioners in primary care would not necessarily improve safety, effectiveness, equity or quality.

A third of the doctors went so far as to state that nurse practitioners would have a detrimental effect on the safety and effectiveness of care.

“These are not just professional differences,” said Karen Donelan, the lead author of the study and a senior scientist at the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston. “This is an interplanetary gulf,” she said, echoing a point in an editorial that accompanied her study.

The findings bode poorly for future policy efforts, since physicians are unlikely to support efforts to increase the responsibilities and numbers of advanced-practice nurses in primary care. And most nurse practitioners are unlikely to support any proposals to expand their roles that do not include equal pay for equal work.

Peter I. Buerhaus, senior author of the study and a professor of nursing at Vanderbilt University Medical Center in Nashville, is chairman of a commission created almost three years ago under the Affordable Care Act to address health care work force issues. But his group has yet to convene because a divided Congress has not approved White House requests for funding.

“We’re running out of time on these issues,” Dr. Buerhaus said. “If the staffing differences remain unresolved, we are just going to cause harm to the public.”

Still, by providing a clearer picture of the extent of these professional differences, the study should help future efforts. “It’s too easy to say that everyone should just get along,” Dr. Donelan said. “These arguments touch on the whole nature of these professions, their core values and how they define themselves.”

“It’s like when family members are warring over a sick patient,” she added. “We need first to acknowledge the others’ position and the full extent of our differences before we can reach any kind of resolution.”

Source: NY Times

Topics: doctor, nurse practitioner, NP

Nurse Practitioner or Doctor of Nursing Practice?

Posted by Alycia Sullivan

Thu, May 23, 2013 @ 03:05 PM

nursepractitioner resized 600
Source: Maryville University Nursing 



Topics: nursing students, Maryville University, doctor of nursing, nursing, practice, nurse practitioner

Should you hire a Nurse Practitioner or Physician Assistant before a physician?

Posted by Alycia Sullivan

Fri, May 17, 2013 @ 12:46 PM

The U.S. is currently seeing a physician shortage that will only continue to rise and affect medical practices all over the country. By 2020, the American Association of Medical Colleges (AAMC) estimates there will be a shortage of more than 90,000 physicians, and that number will grow to 130,000 by 2025.

To solve this problem, many healthcare providers are turning to Nurse Practitioners (NPs) and Physician Assistants (PAs). While many people believe NPs and PAs are unable care for patients as well as physicians, studies have found that to be untrue.  Victoria Garment, editor at SoftwareAdvice.com--a website that presents reviews and ratings of healthcare technology-- explains:

“Decades of studies have demonstrated that, when permitted to practice to the full extent of their training, NPs and PAs can perform a majority of the tasks that physicians do while providing the same quality of care.”

These tasks can include performing physical exams, diagnosing and treating conditions such as diabetes or high blood pressure, writing prescriptions, order diagnostic tests and more. Additionally, “while PAs cannot practice independently of physicians, there are approximately 250 practices across the U.S. that are run solely by NPs,” Garment said.

Another benefit of hiring NPs and PAs is the significant cost savings:

  • Reduced salary expenses - The average base salary of a physician is more than double that of NPs and PAs.
  • Lower overhead costs - Studies show PAs require lower overhead costs than physicians by department, patient demographics and medical care resource use, resulting in a $30,000 boost to the bottom line.
  • Lower costs of care - The costs of NP-managed practices have been found to be 23 percent below physician-managed practices. This can lead to statewide savings of $4.2-$8.4 billion.
  • Higher patient volumes - Another study found that adding an NP to a practice can double patient numbers and boost yearly revenue by $1.65 million per 100,000 enrollees.
  • Reduced insurance and liability costs - Not only is a PA’s liability risk cost one-third of a physician’s, but NPs also have much lower rates of malpractice claims and lower costs per claim.

What’s more, patients often report having an equal or even better experience with an NP or PA compared to a physician. A survey by Medscape found that 80 percent of patients felt NPs “always” listened while carefully compared to 50 percent of physician patients. Similarly, the Kaiser Permanente Center for Health Research released a report that said PA patients ranked their satisfaction levels between 89 to 96 percent for the quality of care they received in the areas of interpersonal care, confidence in the provider and understanding of patient problems.

With all the benefits that NPs and PAs bring, they can be a great addition or alternative to any medical practice, especially those experiencing physician shortages.

To read the full report on The Profitable Practice blog, visit: “Nurse Practitioners and Physician Assistants: Why You Should Hire One (or the Other).”

Topics: physician, physician assistant, AAMC, costs, liability, nurse practitioner

Free the Nurses

Posted by Alycia Sullivan

Fri, Apr 26, 2013 @ 03:40 PM


A nurse practitioner, checks a patient'x blood pressure in Lodi, Ohio July 9, 2012. As of early April, you can walk into Walgreens in 18 states (plus D.C.), and along with a gallon of skim milk, a pair of photo mugs, a six-pack of toilet paper, and a flu shot, you can meet your new primary care provider, get your cholesterol checked, pick up your statin, and schedule a return visit. That primary care provider will not be a physician but a nurse practitioner (or a physician assistant, but that’s for another article). Those states, and now Walgreens, have recognized that nurse practitioners can handle a lot more than antibiotics for urinary tract infections: They can practice primary care just fine without physician oversight. And it’s a pretty smart move.

Lagging behind are the other 32 states (thismap lays it out), in which nurse practitioners are supervised to varying degrees by physicians, the scope of their practice restricted by laws that vary from state to state. In some states, nurse practitioners can’t enroll a patient in hospice, order a wheelchair, or prescribe certain medicines without a doctor’s signature. This is true even when it’s impractical geographically and financially, not to mention belittling. Nurse practitioners in a number of states, including Connecticut, Nevada, and West Virginia, are currently pushing for legislation for the right to practice independently and improve access to care.

The time is ripe: Despite new medical schools designed to attract students interested in primary care, the long dwindle of interest in the field has left a gaping hole, and it’s growing. When an additional 32 million or so Americans are covered through the Affordable Care Act next year, the primary care physician shortage could be catastrophic; it’s estimated to climb as high as 45,000 too few primary care physicians by 2020. Anyone who’s looked for a new physician recently has probably heard some variant of this: “The doctor isn’t taking new patients, but you can see the nurse practitioner or the physician assistant.”

When I called Linda Pellico, associate professor at the Yale School of Nursing and director of the Graduate Entry Prespecialty in Nursing program, she didn’t mince words. “Lifting the barriers on the scope of practice will solve the health care dilemma,” she said, pointing me to the nearly 700-page 2010 report by the Institute of Medicine called “The Future of Nursing.” The document, co-authored by Donna Shalala, recommends that nurse practitioners practice independently, without restrictions, to the “full extent of their education and training.”

The nurse practitioners I’ve worked with as colleagues (I’m a primary care doctor, and I’ve practiced in clinics in Baltimore, New York, and Connecticut), and those who have taken care of me have been pretty awesome. When I was pregnant, I saw a middle-aged lanky nurse midwife who had a wry and down-to-earth sense of humor. He didn’t exude that sense of impatience that you get with so many doctors, that feeling that you’re holding him up from something more important. When I have questions about my very old patients, many of whom have dementia complicated by agitation or insomnia and who are not responsive to my usual bag of tricks, my go-to person is not a psychiatrist—she’s a gerontological nurse practitioner.   

For some doctors, a larger number of independent nurse practitioners would be great news: John Schumann, a general internist who runs the University of Oklahoma–Tulsa internal medicine residency program, told me that he welcomes all hands on deck: “We should be happy when people from other career lines want to work in primary care. Primary care is hard and undervalued, and doctors should not have a monopoly on it.”    

So I was surprised when some of the most open-minded doctors I know hesitated before offering their take on the issue. Most echoed some of the concerns of the major physicians' organizations: If collaboration with a physician becomes optional, will nurse practitioners know when to ask for help? And if primary care doctors need to attend four years of medical school and three of residency, can just three years of nurse practitioner postgraduate training create competent clinicians?   

But making a head-to-head comparison is tricky. Unlike the broader and basic science-heavy education of medical students, nurse practitioner students (many already having a few years of nursing experience) get practical right away and select a specialty— such as pediatrics, geriatrics, anesthesia, family, or midwifery—immediately upon beginning their training. During the corresponding years, medical students are studying subjects like embryology and biochemistry and learning the basics of how to talk to patients. Once nurse practitioners graduate, some opt for a year of additional training in a nurse practitioner residency program. (Newly minted doctors at that point will have chosen a residency specialty and will embark on at least three more years of training.) A few more years in training and nurse practitioners can earn a doctorate in clinical nursing—a DNP, which the Institute of Medicine report recommends for all advanced-practice nurses as of 2015.

Meanwhile, medical training is getting a makeover, so the difference between nurse practitioners and doctors—at least in terms of years of training—is lessening. The 100-year-old paradigm is on the chopping block in many medical schools, and some schools and hospitals are already cutting the length of med school and residency training. (Let’s not even get into the outdated prerequisites for med school. Suffice it to say that I learned more about caring for patients by reading Chekhov than studying organic chemistry.) According to Ezekiel Emanuel, doctors' training could be shortened by about 30 percent. Medical-school graduates of six-year training programs (which collapse the usual eight years of college and medical school into six) don’t do any worse on board exams; some schools already offer a three-year track. For internal medicine residency, Emanuel argues that three years is unnecessary; many programs have long offered two-year “short-track” options for residents eager to jump into a specialty, so why should training for primary care be any different? In my primary care residency, I spent many months on inpatient and intensive care unit rotations. This made more sense in the mid-1990s, when most primary care doctors still rounded on their own hospitalized patients. Nowadays, with hospitalists running many of the inpatient wards, many primary care physicians are becoming almost exclusively outpatient. 

The Institute of Medicine report highlights a number of studies that show that nurse practitioners provide as good care with as good outcomes as primary care physicians, along with high rates of patient satisfaction. In one of the most-cited studies, 1,316 mostly Hispanic patients were randomly assigned to see either doctors or nurse practitioners, and the outcomes of patients with diabetes and asthma were about the same. But the trial only lasted six months, which is a pretty short period of time in primary care for drawing conclusions about disease management and the patient-provider relationship. Whether you can extrapolate these findings to patients of different ages and backgrounds and to all of the chronic conditions that surface in primary care (and Walgreens) remains unclear.

Primary care is not an easy field to master; the breadth and depth of knowledge is vast, unlike the narrower world of the shoulder specialist, who only sees patients with shoulder problems. Sure, every now and then there’s the glamour of cracking a diagnostic mystery case, the chance to dredge up some obscure and critical fact buried in our overloaded brains, but most of the time it’s like this: We talk. We listen. (Hopefully, we listen more than we talk.) We treat common illnesses and try to prevent chronic ones. We learn about where our patients live, what they eat, who they talk to, how they get around. We listen to the patient whose marriage is on the rocks and relate this to her elevated blood pressure. We coordinate care and help devise a plan when multiple specialists are giving different and sometimes contradictory recommendations. We make a lot of phone callsand answer a gazillion emails. When we’re not sure about something, we look it up, or knock on a colleague’s door, or call across town or across the country. And because primary care is all of these things, an ever-evolving conglomeration of medical knowledge and systems and empathy and integrity and creativity in problem-solving, this is precisely why it’s good to mix it up and reap the benefits of some nurse practitioner-doctor hybrid vigor.

This is why I think nurse practitioners should be released from their arbitrary bondage and do what they are trained to do, what they’re board-certified to do, and what many do so well: take care of patients and collaborate with physicians because they want to, not because they have to. Nurse practitioners and doctors should welcome each other’s perspectives, experiences, and abilities. As physician assistant and researcher Roderick Hooker told me in an email, “America is a nation of innovators and the advancement of medicine and nursing are no exceptions. Nurse practitioners and physician assistants are part of the social experiment to deliver healthcare in beneficial and effective ways. The independence of [nurse practitioners] is merely another step in this social experiment."

It’s time to unlock the gates to the primary care club. There will be plenty of patients for everyone.

Source: Slate

Topics: independence, healthcare, doctors, nurse practitioner, clinics

Nurse Practitioners Push To Help Care For Health Law's Newly Insured

Posted by Alycia Sullivan

Fri, Feb 22, 2013 @ 12:16 PM

By Alvin Tran

More than 27 million Americans will soon gain health coverage under the health law. But who will treat them all?

describe the imageWith such a large coverage expansion, and with an anticipated shortage of primary care physicians available to serve them, some states have or are considering allowing so-called advanced practice nurses -- those with advanced degrees -- to treat more patients. David Hebert is at the issue’s center. Hebert, a veteran health care lobbyist and former CEO of the American College of Nurse Practitioners, is the first CEO of the American Association of Nurse Practitioners (AANP) -- a new group with 42,000 members recently formed from the merger of the American College of Nurse Practitioners and the American Academy of Nurse Practitioners.

Hebert says that despite doubts from some doctor groups, nurse practitioners are honing their craft in patient care and research to position themselves to help care for this new influx of patients, and they’re doing so without sacrificing the quality of care.

KHN's Alvin Tran sat down recently with Hebert to discuss the changing role nurse practitioners may soon have, as well as some physicians' efforts to stop them.

Here are edited excerpts of that discussion:

Q. As of 2012, 18 states and the District of Columbia allow nurse practitioners to diagnose, treat patients and prescribe medications without a doctor’s involvement. What is the biggest impediment to expanding to other states? How are you planning to expand that to the other states?

Well, the problem is that there are certain states that require physicians' supervision of nurse practitioners or there may well be some kind of restrictive collaborative agreement that is imposed upon the nurse practitioner. Often times, that makes it very difficult for nurse practitioners to practice. Sometimes there may be a physician who is unwilling to supervise. Other times you may have an issue where the physician chooses to not form a collaborative agreement with nurse practitioners. So, part of the issue is that we have anticompetitive regulations in place.

There are a number of things that we want to do at the federal level. We are hopeful that legislation is going to be reintroduced this Congress that will allow nurse practitioners in Medicare to admit patients for home health care. Right now, the admission can only be done by a physician. Given the fact that we've had research indicating that it would be cost effective, we can get people out of nursing homes and hospitals quicker. It really makes good public policy sense. Particularly, if you got a situation in a rural area where the nurse practitioner and the patient is waiting for the physician to sign the order to admit into home health.

Same thing is true on hospice. We've not been able to get legislation passed that allows nurse practitioners to admit to hospice. We’re not currently permitted by statute to formaccountable care organizations on our own. That opens up a lot of possibilities for safe and effective, cost effective health care.

Q. Physicians groups, including the American Medical Association, have opposed efforts to expand the scope of practice of nurse practitioners and raised concerns of patient safety, contending that physicians' extended training makes them more qualified to handle such issues. How do you make sure that patients are protected?

There have been studies over the years that shows that our outcomes are the same or better than primary care physicians. The fact is that it’s a total red herring. Nurse practitioners have been practicing safely and providing great outcomes for decades.

Q. Medicare’s reimbursement rate for NPs is 85 percent of the physician rate for the same services. Should these rates be the same for both providers?

One hopes that, when all is said and done, whether they're working with a physician or billing on their own, it should be 100 percent of what a doctor is paid because the fact is, they're providing the same services that a physician is providing. Quite frankly, it doesn't make any sense.

Q. What role do you think NPs will have once the federal health law takes effect in 2014?

I think that once you have a full implementation of the expanded Medicaid provisions of the ACA, you’re going to see increased demand for primary care. Unless there’s someone there to provide that care, the intent of the ACA will not be fulfilled. You’re going to see a lot of patients who may be insured or have coverage under Medicare and Medicaid, but may not be able to get services.

I think the major challenges will be to look at regulations that artificially restrict a nurse practitioner’s ability to practice within their scope. If patients want to choose a nurse practitioner, they should be free to do so.

Q. Your tenure as CEO began last month, what’s at the very top of your 'to-do list'?

We are looking at rebranding and a more enhanced public relations campaign. We're looking at increasing membership. Right now we’re about 42,000 members and there are 155,000 nurse practitioners in this country. So, we have room for growth. We’re going to be spending some time ramping up our association activities.

Source: Kaiser Health News

Topics: AANP, insured, health law, advanced practice nurse, health, nurse practitioner

More independence sought for 5,000 nurse practitioners

Posted by Alycia Sullivan

Fri, Dec 21, 2012 @ 03:09 PM

Article by: MAURA LERNER

For years, nurse practitioners in Minnesota have been able to see patients only in association with a licensed doctor. But a governor's task force says it's time to let those nurses work independently -- in part, because of a coming shortage of primary care physicians.

The proposal, which has been opposed by physician groups, was endorsed Thursday in the final report of the state Task Force on Health Reform, headed by Human Services Commissioner Lucinda Jesson. The report is expected to set the stage for a debate in the Legislature, which must approve any changes.

The plan would lift restrictions on the state's more than 5,000 "advanced practice nurses," who get extra training to diagnose and treat many routine conditions, from strep throat to chronic illnesses.

Under current law, they must have a working agreement with a physician, although 17 other states have no such restrictions.

"The reality is that we've got a primary care shortage and you can't turn out doctors fast enough," said Dr. Therese Zink, a University of Minnesota physician who served on the task force. "We can't afford to wait. We need creative solutions."

Many advanced practice nurses already operate semi-independently, running clinics in drug stores, schools, rural areas and other locations, under "collaborative agreements" with physicians. The problem, said Zink, is that if the physician retires and no replacement is found, the nurse practitioner would have to close up shop. "It's probably, more than anything, a rural access issue," she said.

But the Minnesota Medical Association (MMA) says the physician oversight is necessary. "This is a patient safety issue," said Dr. Dave Thorson, a St. Paul physician and chairman of the MMA's board of trustees. "I think nurse practitioners ... do a wonderful job. They're a valuable member of the health care team. But they're not the same as a physician, so they shouldn't be given the same scope of practice as a physician."

The American Academy of Family Physicians also objects to the idea. "Substituting nurse practitioners for doctors cannot be the answer," it said in a report in September. It noted that doctors are required to go through twice as many years of training (11 years) as advanced-practice nurses (five to seven years).

But the trend has been spreading. Today, 17 states, including Iowa and North Dakota, permit advanced-practice nurses to diagnose and treat patients, as well as prescribe drugs and devices, without physician supervision, according to the task force.

One of the driving forces is the anticipated physician shortage, as large numbers of doctors retire and aging baby boomers need more care. National experts predict a shortage of 45,000 primary care doctors by 2020.

"We're trying to stay ahead of the curve," Zink said. "We've got to have solutions that are above and beyond and push the envelope."

The task force report, which includes a broad range of recommendations on quality and access to care, will be posted Friday on the Minnesota Health Reform website, mn.gov/health-reform.

Topics: independence, shortage, nurse practitioner, care

Associations Merge to Form Unified Voice for Nurse Practitioners

Posted by Alycia Sullivan

Wed, Dec 05, 2012 @ 05:00 PM

describe the image By Katie Bascuas / Nov 27, 2012

Two nurse practitioner trade associations are joining forces to better advocate for their members and to help their members better advocate for patients.

Beginning next year, nurse practitioners will have a single, collective body representing them in Washington, DC, as well as promoting education and research in the field.

As of January 1, 2013, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners will merge to form the American Association of Nurse Practitioners, both organizations announced last week.

“We felt like it was the right time for there to be one national nurse practitioner organization representing all specialties at the national level,” said Angela Golden, president of the American Academy of Nurse Practitioners. “This new organization gives us the opportunity to have that one strong, unified voice to move good quality patient care forward.”

The new association will also make it easier for nurse practitioners interested in joining a professional organization but confused by which one to join.

“I think the members will continue to see the same strong organization that they’ve come to expect, but nurse practitioners will not have to decide anymore, ‘Do I have to pay membership to two organizations,’” Golden said. “There’s one organization with their best interest at heart, moving things forward.”

By aligning resources and working together, “we’re going to be able to have the best of both worlds,” said Jill Olmstead, former president of ACNP. One of the biggest benefits includes a stronger legislative platform.

“I’m hoping that this will actually give the average nurse practitioner the opportunity to become more involved within their profession and advocate for improved access to patient care,” Olmstead said. “Nurse practitioners are wonderful at advocating for their patients, and I think the organization is trying to help inspire [them] to advocate for their profession.”

With the growing shortage of primary care doctors and new healthcare care laws creating a large contingent of newly insured Americans, nurse practitioners are becoming increasingly pivotal players in the U.S. healthcare system.

“Whether it’s one organization or not, nurse practitioners are so focused on the patient care, and as healthcare reform comes in,” Golden said, “our focus has to stay where it always has been and that’s on our patients.”

Topics: association, AANP, ACNP, advocate, nurse practitioner

Nurse Practitioners Step In Where Doctors Are Scarce

Posted by Alycia Sullivan

Wed, Dec 05, 2012 @ 04:56 PM

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BUCKINGHAM COUNTY, Virginia – Most people in this rural logging area have only one choice when they need medical care: the Central Virginia Community Health Center. On most days, at least 200 people show up at the center seeking treatment for maladies ranging from sore throats to depression to cavities.

The health center typically has four doctors on duty, but the clinical director, Dr. Randall Bayshore, says his staff would never meet local demand if it weren’t for the two nurse practitioners who provide the same care, to the same number of patients, as the doctors.

Buckingham County is one of roughly 5,800 U.S. communities, with about 55 million residents, that have a shortage of primary care physicians. In these places, many residents are forced to forgo regular checkups and treatment for chronic diseases such as hypertension and diabetes — harming their overall health.

In 2014, when the new federal health care law extends insurance coverage to 30 million more people, the doctor shortage is likely to get worse. Anticipating this, states and the federal government are offering repayment of medical school loans and other incentives to encourage newly minted doctors to practice primary care in needy areas.

But efforts like these take years to pay off. So as an additional step, states are trying to loosen decades-old licensing restrictions, known as “scope of practice laws,”  that prevent nurse practitioners from playing the lead role in providing basic health services.

Nurse practitioners, registered nurses with advanced degrees, are capable of providing primary-care services such as diagnosing and treating illnesses, prescribing medication, ordering tests and referring patients to specialists. But only 18 states and the District of Columbia currently allow nurse practitioners to perform these services independently of a doctor.

Political tension

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A 2010 Institute of Medicine report, “The Future of Nursing,” cited nearly 50 years of academic studies and patient surveys in concluding that primary care provided by nurse practitioners has been as safe and effective as care provided by doctors. But efforts to change “scope of practice” laws to give nurse practitioners more independence have run into stiff opposition.

Organized physician groups, which hold sway in most legislatures, are reluctant to cede professional turf to nurses. Arguing that nurse practitioners lack the necessary level of medical training, they insist that it is unsafe for patients to be treated by nurse practitioners without a doctor’s supervision.

Some doctors also have a financial incentive to limit nurses’ independence. Often carrying heavy medical school loan debt, they can be loath to see their revenue diverted by competing health care services, particularly those with lower fees. The Federal Trade Commission has weighed in on legislative efforts to give nurse practitioners more autonomy in several states, arguing that physician groups have no valid reason for blocking such laws other than to thwart their competition.

Virginia is a case-in-point. After several failed attempts over the last decade, the legislature finally passed a nursing “scope of practice” law in 2011 that doctors and most nurse practitioners in the state say is a step forward. According to its authors, the aim of the law is greater patient access to primary care across the state.

Instead of requiring supervision by a doctor, Virginia’s new law requires nurse practitioners to be part of a doctor-led “patient care team.” And instead of limiting doctors to overseeing just four nurse practitioners, the law allows them to work with up to six. Most important, it removes a requirement that doctors regularly work in the same location as the nurses they supervise. Instead, the statute allows doctors and nurses in separate locations to use telemedicine techniques to collaborate.

The American Medical Association and the American Academy of Family Physicians have called Virginia’s first-of-its-kind law a model for other states that still require on-site doctor supervision of nurse practitioners.

According to Dr. Cynthia Romero, who was president of the Virginia Medical Society when it negotiated with the Virginia Council of Nurse Practitioners to create the law, “the turning point was when both sides realized that the primary focus had to be what was best for patients.” She says the new law is a step forward for patients and builds a bridge between doctors and nurses. “The road ahead is limitless,” she says.

Mark Coles, the chief negotiator for the nurse practitioners' council, is less enthusiastic but says the law represents progress. “It gives us a seat at the table in the legislature for future improvements,” he says.

But in certain parts of the state, nurse practitioners say the new law may be a step in the wrong direction. They worry about new language that requires them to consult with supervising doctors on all “complex” cases. Although rules scheduled to be released next month may clarify which cases are considered complex, some nurse practitioners fear the definition may be subject to differing interpretations.

The American Academy of Nurse Practitioners and other nursing organizations recently issued a position paper opposing the whole idea of requiring nurse practitioners to join a doctor-led team if they want to practice to the full extent of their training.

“We broadly support team-based care when it reflects the needs of patients, says Tay Kopanos, head of government affairs for the academy. But when a nurse practitioner can’t bring her best efforts to a clinic without joining a doctor’s team, Kopanos says, “we do not support it.”

Difficult terrain

About 300 miles southwest of Buckingham County – in the Appalachian Mountains where Virginia shares borders with Tennessee and Kentucky—the shortage of health care providers is profound. Working out of a converted recreational vehicle known as the Health Wagon, two nurse practitioners, Teresa Gardner and Paula Meade, do their best to serve a four-county region where idle coal mines have left many jobless and without health insurance.

The non-profit Health Wagon, started in 1980 by a Catholic missionary, has expanded its reach over the years to meet the growing demand of a population that is sicker than most in the country. But the steep and winding roads, often coated with heavy snow and ice in winter, make it dangerous and sometimes impossible to reach everyone in need.

At the Central Virginia Community Health Center in Buckingham County, where doctors and nurses practice side-by-side, the new Virginia law may not present a problem. The kind of ongoing collaboration between doctors and nurse practitioners called for in the law happens naturally in the course of every day. The same thing goes for doctors and nurse practitioners working together in hospital settings.

But, Meade says, team collaboration could be dicey in the hollers of Appalachia. “I’d love to start every day with a multi-disciplinary team meeting,” she says. “Nothing would make me happier.” Driving a mobile unit along treacherous highways and seeing at least 45 patients every day in cramped quarters, however, doesn’t leave much time for meetings.

Sicker than most

What she and Gardner fear most is the requirement in the Virginia law that nurse practitioners consult their lead doctor on all “complex” cases. Gardner and Meade collaborate with each other throughout every day and they often seek advice from their volunteer supervisor, Dr. Joseph Smiddy, who at 70 years old, still has a day job practicing medicine across the border in Kingsport, Tennessee.

“Dr. Smiddy would murder me if I called him every time a complex case walked through the door,” Gardner says. “They’re all complex. Most of them are train wrecks. I’d love to treat someone with a common cold.”

For his part, Smiddy says any law that would increase the pressure on nurse practitioners willing to work in remote mountain areas has got to be the wrong approach. He plans to ask his lawyer to review the statute to see whether it increases his own medical liability as a volunteer team leader.

He agrees that nearly all of the Health Wagon’s cases are complex, no matter how the law defines that term. The area has a high incidence of COPD (chronic obstructive pulmonary disease), heart disease, diabetes, obesity, cancer, prescription drug abuse and mental illness. More than a few patients have 10 diagnoses, Smiddy says, and many are on 30 different medications.

“Teresa and Paula are brilliant doctors," Smiddy says. "They need to be a national example – a model for how to do it for the rest of the country… We’re not ever going to have enough doctors willing to ride around in a mobile unit the way they do. They’re the real deal. We need to do everything we can to support them.” he says.

Topics: patient, doctor, nurse practitioner

New Clinics Fill a Niche for Routine Health Care

Posted by Alycia Sullivan

Fri, Nov 30, 2012 @ 03:10 PM

By Kristine Crane


describe the imageNurse practitioner Denise Snyder likes to think of Gainesville's new MinuteClinic as a one-room schoolhouse. It has just about everything you'd find at a doctor's office: blood pressure cuffs, flu vaccines, strep tests, an eyesight chart, and even a stack of toothbrushes for people with strep throat, since they are supposed to use a different toothbrush within 24 hours of taking antibiotics.

The one-stop clinic -- Gainesville's first MinuteClinic -- opened two weeks ago inside the CVS at 3404 SW Archer Road, and another one will open next month in the CVS at 4354 NW 23rd Ave.

The clinics, numbering more than 600 in the U.S., specialize in treating minor illnesses and injuries, monitoring chronic conditions such as diabetes and high blood pressure, and doing routine physicals and vaccinations. Their intent is to fulfill a need in between an urgent care clinic and a primary-care doctor's office.

MinuteClinic is one of a few local clinics that in the dawn of health-care reforms is set to make health care more accessible. The University of Florida and Shands opened a Family Medicine Clinic at Jonesville on Nov. 1, which covers preventive care, immunizations, sports physicals, women's care and pediatric and adult care. And an Alachua County Health Department (ACHD) clinic will open next summer off Southwest 24th Avenue in southwest Gainesville to serve disadvantaged patients, the ACHD announced Tuesday.

Snyder, who is MinuteClinic clinical practice manager for Northwest Florida and Gainesville, said the goal of MinuteClinic is not to replace primary care practices but rather "to be an extension of that."

"We're out in the community and very accessible for minor conditions and basic care," added Dr. Nancy Gagliano, the medical director of MinuteClinic, which is a subsidiary of CVS and headquartered in Woonsocket, R.I.

"With health reform and just the general shortage of primary-care physicians, the country needs to be innovative at finding patients affordable care," said Gagliano.

Minor illness visits cost $79, and flu and strep tests $30. Overall services are estimated to cost 80 percent less than they do at the ER and 40-50 percent less than they do at primary-care clinics. MinuteClinic accepts most major insurance plans. According to some estimates, retail health clinics such as MinuteClinic, which launched in 2000, could reduce health-care costs by $350 million by 2020.

The clinic is mostly staffed by nurse practitioners, and because of that has a holistic approach to treatment, explained Tracie Mitchem-Green, a nurse practitioner at the Gainesville clinic. "We don't just throw a medicine at it. We're very evidence-based," she said, adding that if someone comes in who's had a cold for a day and wants antibiotics, they won't necessarily prescribe one. "We're all about educating patients."

An "Ask Me 3" brochure that patients get has three questions that patients should ask when they come in: What is the problem? What do patients need to do about it? Why is it important for them to follow through with treatments?

"We don't just give them a Z-pac and send them out the door," Snyder added. "If it's a virus, the body has to heal."

The clinics' location inside a CVS store is convenient -- since nurses can show people which medications to buy from an often overwhelming plethora of choices, said Snyder.

Since the clinic opened, Mitchem-Green has had a lot of patients with sore throats. That's why Kyle Johnstone wandered into the CVS where the MinuteClinic is on Tuesday. He was looking for cough syrup for his sore throat, which developed after he spent the weekend with a nephew who had strep throat. Johnstone said he couldn't get into his primary-care physician for another two weeks, so he decided to wait 20 minutes to be seen at the MinuteClinic instead.

The pharmaceutical representative squeezed in the visit between work appointments. "If I'm walking into a lot of offices, I don't want to spread germs," said Johnstone.

Kimberly Greenwood, a nursing student, also came to the clinic Tuesday with a sore throat and discovered she had an upper respiratory virus, so she stocked up on some Sudafed and was headed home after being seen.

A native of Ohio, Greenwood had been going to MinuteClinic there for several years. "If you're a student and constantly moving around, it's a really good thing to have," said Greenwood, adding, "I don't want to go to urgent care clinics and take care from people who need it."

And that's precisely MinuteClinic's mission. "We can free up the primary-care physician a little bit to take care of more patients and sicker patients," Gagliano said, adding that the clinics are convenient for people to stay on top of regulating their glucose or blood pressure. "With the aging of the population, there's just more care people are going to need ... this is almost a safety net in the community."

The ACHD clinic aims to be a safety net as well, in Gainesville's southwest neighborhoods. "We know that the area has tremendous unmet needs," said Diane D'imperio, director of program development at the ACHD. The area, known as the "southwest triangle," has the county's highest concentration of Medicaid births and babies of low birth weight. It also reports the highest number of ER visits per capita.

"We think (the clinic) will make a huge difference both in terms of reducing ER visits and improving overall health," said D'imperio.

One of the clinic's partners is SWAG, the Southwest Advocacy Group, which is right across the street from where the clinic will be. SWAG provides educational, health and community resources to people in the area.

"Having the SWAG clinic there is an automatic outreach," said D'imperio. "People might come there looking for food or clothes...the staff there will really be able to encourage people to come. They'll be able to function like an advisory group."

Topics: minute clinic, CVS, nurse practitioner

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