Download AKAMSP 2016 - Scope of Practice for Advanced

Alaska Association of Medical Staff
Professionals
June 16, 2016
Scope of Practice for Advanced Practice Staff
in the Eyes of TJC & CMS
Catherine Ballard, Esq., Executive Director
The Quality Management Consulting Group, Ltd.
and
Partner, Bricker & Eckler LLP
[email protected]/[email protected]
614.227.4848/614.227.8806
10089777v1
Background
APRNs: 128,000 in 2008 projected to be
244,000 in 2025.
PAs: 74,476 in 2010 projected to be 127,821 in
2025.
Surveys of medical school graduates indicate
that roughly 2% of graduates are choosing
primary care.
© QMCG 2016
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Background
• Affordable Care Act (ACA) and accompanying
expansion of Medicaid in many states has led
to increased demand for primary care services
at traditional locations (i.e., physician office).
• American Academy of Family Physicians
estimates U.S. will face shortage of 60,000
primary care physicians by 2020.
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What is Scope of Practice?
• A Federation of State Medical Boards report
defined scope of practice as the:
– “Definition of the rules, the regulations, and the
boundaries within which a fully qualified
practitioner with substantial and appropriate
training, knowledge, and experience may practice
in a field of medicine or surgery, or other specially
defined field. Such practice is also governed by
requirements for continuing education and
professional accountability.”
© QMCG 2016
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Scope of Practice
• Each state separately regulates the scope of
practice for Advanced Practice Providers.
• In addition to State rules and statutes, scope
of practice can be affected by credentialing
and privileging decisions at hospitals and
federal regulations.
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Current Scope of APP Practice
• Varies widely by state and specialty
– In some cases, specific legal requirements for
physician involvement continues to limit the
services APPs can provide and sites of service
where they can practice.
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Current State of APP Prescriptive Authority
• Barriers to enhancement of prescriptive authority
continue to be removed.
• In most states, APPs can prescribe drugs with varying
degrees of physician involvement.
• Majority of states continue to require physician
collaboration/supervision for controlled substance
prescribing.
• Some states continue to have specific formulary
limitations, although the formularies in many states are
expanding.
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Current State of Admitting Privileges
• Trend towards including admitting privileges
within the scope of practice.
• As state laws change to allow APPs to admit,
must look at whether language in the statutes
is mandatory or permissive.
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Advanced Practice Registered Nurses
(APRN)
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APRN Definition – The Joint Commission
Advanced Practice Registered Nurse:
• Registered nurse who has gained additional
knowledge/skills through successful completion of
an organized program of nursing education that
prepares nurses for advanced practice roles and
who has been certified by the Board of Nursing
to engage in the practice of advanced practice
nursing.
© QMCG 2016
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APRN - History
• Modern nursing is usually pinpointed as beginning in 1873.
• Emergence of a strong public health movement in the 19th century
coupled with other occurrences are noted to have created a vehicle
for independent and autonomous nursing practice.
• 1960s
– National shortage of primary care physicians led to a gradual
expansion of nursing practice.
• 1965
– The first nurse practitioner program at the University of
Colorado was designed to prepare registered nurses (RNs) to
manage childhood health problems.
– Was viewed by some as a “siphoning off” of talented nurses into
a form of medical practice.
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APRN - History
• 1960s – 1970s
– Rapidly emerging technology and advances in
coronary care medicine fueled the desire for
nurses to gain in-depth knowledge and expertise.
• 1970s
– Universities began to develop graduate programs
for APRNs in critical care and cardiovascular
nursing.
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Brief Note on Terminology
• Specialist in nursing
– Traced to the turn of the 20th century when it was used to designate a nurse who
had completed a postgraduate course in a clinical specialty area or who had
extensive expertise in a specific clinical area.
• Introduction of the APRN roles in the 1960s and the terms expanded role
and extended role
– Used to imply horizontal movement to encompass expertise from medicine and
other disciplines.
• Advanced practice (1980s)
– Reflects a vertical or hierarchical movement encompassing graduate education in nursing.
• Advanced Practice Nurse (post 1980s)
– Increasingly used to delineate the four roles (CNP, CRNA, CNS, and CNM).
• Advanced Practice Registered Nurse (the last decade)
– Adopted by state nursing practice acts.
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APRN – Across the U.S.
• American Association of Nurse Practitioners
(AANP) estimates there are more than 205,000
nurse practitioners practicing in the U.S.
– 17,000 new APRNs completed their academic
programs in 2013-2014
• Of the APRNs currently working in the U.S., 80%
are prepared in primary care specialties.
– Have been in practice an average of 10 years.
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Current Scope of APRN Practice Categories
• Independent – no requirement for a written
collaborative agreement, no supervision, no conditions
for practice.
• Not Independent – a written agreement exists that
specifies scope of practice and medical acts allowed
with or without a general supervision requirement by
a MD, DO, DDS or podiatrist; or direct supervision
required in the presence of a licensed MD, DO, DDS
or podiatrist with or without a written practice
agreement.
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By the Numbers: Current State of
Independent Practice
• 21 states and the District of Columbia allow nurse
practitioners to practice independent of a physician.
– Some require APRNs to spend a set time in an arrangement
with a physician before they gain independent prescribing
rights.
– Maryland is the most recent state to allow independent
practice.
• 17 states require that APRNs have a reduced practice
and require either a collaborative arrangement or set
other limits on the scope of APRN practice.
© QMCG 2016
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By the Numbers: Current State of
Independent Practice
• 12 states require “supervision” or team
management with a physician, with those nurses
prescribing through the physicians.
• Collaborative agreements, which are made official
with forms signed by the APRN and the physician,
can vary widely.
– Kentucky, for instance, has never required physicians
to review the APRNs’ prescribing patterns or meet
with APRNs regularly
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Marching Towards Independent Practice
The Consensus Model for APRN Regulation: Licensure,
Accreditation, Certification, and Education
– Referred to as the “APRN Consensus Model.”
• Proposes uniformity to APRN related issues, such as the
scope of practice and the lack of uniformity in education
and state regulations.
– Endorsed by 44 nursing organizations.
– Proposes that APRNs will be licensed independent
practitioners who are expected to practice within the
standards established or recognized by a licensing body.
– Full implementation target date was 2015.
© QMCG 2016
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APRN – State-Based Status
©Copyright 2016 Bricker & Eckler LLP
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Why is this happening?
• Expansion of health insurance + aging
population =
– Heavy demand for primary care
– A shortage of primary care physicians
– Demand to lower costs
– Pharmacies creating clinics as “loss leaders”
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Where do we see APRNs?
•
•
•
•
Retail clinics
Physician offices
Embedded in employer settings
Hospital settings
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Alaska APRNs
– Alaska recognizes “advanced nurse practitioners”
– To qualify as an APRN, a registered nurse must:
• Complete a one year academic course of study that prepares the nurse for an
expanded role
• Hold a current certification of a nurse practitioner in a specialty area of nursing
granted by a national certification body
• Have a written plan that is kept by the Alaska Board of Nursing
– Written plan must:
• Describe APRN’s practice
• Identify expected category of clients
• List APRN’s method for routine and emergency consultations and referrals
• List the planned pharmacist for potential use of dispensing privileges
• Describe the quality assurance process that will be used to evaluate the APRN
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Alaska APRNs
• Alaska defines the scope of practice for
APRNs as the “described in the scope of
practice statements for nurse practitioners
certified by national certification bodies
recognized by the Board.”
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Alaska APRNs
– APRNs who apply for authorization can prescribe and
dispense legend drugs
• Alaska Board of Nursing publishes a quarterly list with the names of all
APRNs who are authorized to prescribe and dispense drugs
– APRNs can also prescribe and dispense schedule II-V control
substances
• Must submit a separate application
• Must have 5 years of prescribing experience prior to applying
– APRNs are not required to enter into an agreement with a
physician to prescribe or dispense
• But they can only dispense a prescription within their scope of
practice
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Physician Assistants
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PA Definition –
The Joint Commission
Physician Assistant (PA):
• Individual who practices medicine with supervision
by licensed physicians, providing patients with
services ranging from primary medicine to
specialized surgical care.
• Scope of practice is determined by state law, the
supervising physician’s delegation of responsibilities,
the individual’s education and experience, and the
specialty/setting in which the PA works.
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PA - History
• Dr. Eugene Stead, Jr. of Duke University assembled the first class of PAs
in 1965.
• Class consisted of 4 Navy Hospital Corpsman who received medical
training during their military service.
• Curriculum was based on fast-track training programs for doctors
during WWII.
• 1970- Kaiser Permanente became first HMO to employ a PA.
• 1971- Comprehensive Manpower Training Act included $4 million for
establishment of new PA educational programs.
• 1975-National Commission on Certification of Physician Assistants
established to determine eligibility criteria and to administer national
certifying exam.
• 1986- Medicare began covering PA services provided in hospitals,
nursing homes and when assisting in surgery.
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PA - History
• 1987- Medicare coverage of outpatient services in
rural and underserved areas.
• 1997- Medicare recognizes PAs as covered providers
in all settings at a uniform rate of payment.
• 2000- Mississippi becomes the last state to recognize
PA practice.
• 2007- Indiana becomes the last state to grant PAs
prescriptive authority.
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PA – Across the US
• The American Academy of Physician Assistants
(AAPA) reports there are more than 100,000
physician assistants working in the U.S.
– More than 7,000 PA graduate from accredited
programs each year.
• Report published in Public Health Reports
predicts that physician assistant workforce will
grow 72% between 2010 and 2025.
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Current Scope of PA Practice - States
• Scope of practice defined at either the practice level or by
statute.
• 16 states still determine scope of practice by statute.
– Certain states allow for broader scope of practice in
hospitals.
• 28 states adapt the supervision requirements according to the
circumstances of the practice.
• 11 states do not place a limit on the number of PAs a physician
can supervise.
• 10 states still limit prescriptive authority to some extent.
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Alaska PAs
• PAs in Alaska cannot practice medicine or osteopathy
independently; must practice under the supervision of a physician
– Must have a documented collaborative plan on a form provided by the
Medical Board
• Alaska PAs must graduate from a program accredited by the
Accreditation Review Commission on Education for Physician
Assistants and pass a certifying examination
• PAs must be certified by the National Commission of Physician
Assistants (NCCPA)
• PAs must have at least one documented collaborative relationship
with a physician
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Alaska PAs
•
The PAs collaborative plan must include:
– The names and specialties for the primary supervising physician and at least one alternate
collaborating physician
– The name, place of employment, and residence of the PA
– The beginning date of employment and the physical location of the practice
– The prescriptive authority being granted to the PA by the collaborating physician under the
plan
•
•
A copy of the collaborative plan must be kept at the place of employment and must be
available for inspection by the public
Any change in the collative plan automatically suspends the PA’s authority to practice
– Changes from the collaborating physician to the listed alternate collaborating physician do not
trigger this suspension
•
PAs may work in a remote practice location
– If the PA has less than 2 years of experience – must work 160 hours in direct patient care
under the direct and immediate supervision of the collaborating physician
– A PA with more than two years of experience – must submit a document detailing the PA’s
previous experience and a written recommendation and approval from the collaborating
physician
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Alaska PAs
• Collaborating physicians must periodically evaluate the
medical care and clinical management of PAs.
– Assessment must be done quarterly for PAs that have been in a
collaborative agreement for less than 2 years
– Regardless of experience - Must include at least a monthly
direct, personal, and documented contact between PA and
collaborating physician
• PAs can prescribe, order, administer, and dispense drugs
(including controlled substances) with authorization from the
assistant’s collaborating physician
– A PA’s authority to prescribe cannot exceed that of the primary
collaborating physician
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Interpretive Guidelines to CMS Hospital
Conditions of Participation (CoP)
CMS CoPs now provide that the governing
body of the hospital has the authority, in
accordance with State law, to grant medical staff
membership and privileges to non-physician
practitioners.
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Interpretive Guidelines to CMS Hospital
Conditions of Participation (CoP) con’t.
For non-physician practitioners granted
privileges only, the hospital’s governing body and
its medical staff must exercise oversight, just as it
would for those practitioners appointed to the
medical staff.
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Interpretive Guidelines to CMS Hospital
Conditions of Participation (CoP)
[Non-physician] Practitioners are defined by CMS as any of the following:
•Physician Assistant
•Nurse Practitioner
•Clinical Nurse Specialist
•Certified Registered Nurse Anesthetist
•Certified Nurse Midwife
•Clinical Social Worker
•Clinical Psychologist
•Anesthesiologist’s Assistant
•Registered Dietitian or Nutrition Professional
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Examples of types of licensed healthcare
professionals who might be eligible for clinical
privileges depending on State law and medical
staff bylaws include, but are not limited to:
•Physical Therapist
•Occupational Therapist
•Speech Language Therapist
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Some States have established a scope of practice
for certain licensed pharmacists who are
permitted to provide patient care services that
make them more like the other types of nonphysician practitioners including the monitoring
and assessing of patients and ordering of
medications and laboratory tests.
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Surgical Privileges (Interpretive
Guidelines to CMS Hospital Conditions of
Participation 42 C.F.R. 482.51(a)(4)
• The hospital must specify surgical privileges for
each practitioner that performs surgical tasks.
• This includes practitioners such as MD/DO,
dentists, oral surgeons, podiatrists, RN first
assistants, nurse practitioners, surgical physician
assistants, surgical technicians, etc.
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Best Practices & Hospital’s Duty to
Ensure Proper Collaboration/Supervision
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Credentialing - Definition
Credentialing:
• Process of obtaining, verifying and assessing
the qualifications of a health care practitioner
to provide patient care services in or for a
health care organization.
• Includes documented evidence, at a minimum,
of current licensure, education, relevant
training, experience, and other qualifications.
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Credentialing – Hospital Responsibility
• Hospital Responsibility: To assure that only
designated healthcare providers who are
qualified, and who continue to be qualified,
exercise privileges at the hospital.
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Best Practices
• The Hospital is responsible for assuring that APRNs and
PAs are qualified to exercise clinical privileges. This means
that
– Privileges must be appropriately drafted
– There must be an ongoing professional review of activities, the
same as for all other individuals with clinical privileges at the
Hospital
– This is easier for independent APRNs as they can be tracked
the same as any other Practitioner with clinical privileges
– This is not as easy for PAs, but it still needs to be done
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Hospital’s Duty to Ensure Proper
Collaboration/Supervision
• Are you reviewing physician’s
collaboration/supervision of the APP’s performance
as part of the physician’s competency?
• More thorough review of APP may assist in better
review in oversight activities.
• If physician is liable for the APP’s activities, the
hospital may ultimately face vicarious liability “up the
chain.”
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Hospital’s Duty to Ensure Proper
Collaboration/Supervision
• OPPE/FPPE
– Consider whether criteria developed to evaluate
the performance of practitioners when “issues
affecting the provision of safe, high quality patient
care are identified” should include APP supervision
– Consider whether problem with APP should
trigger FPPE collaborating/supervising physician
• Who’s conducting quality oversight of APPs?
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Negligent Credentialing
Medical Staff Oversight
• Medical Staff governing document should describe
collaboration/supervision duties and requirements and
that failure to collaborate/supervise is grounds for
corrective action
• Medical Staff governing document should explain
requirements for bringing in new APPs to hospital and
obligations of physician
• Hospitals can/should have their own rules
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Hospital’s Duty to Ensure Proper
Collaboration/Supervision
• Strategies
– APP Policy
• Part of Bylaws or Medical Staff governing documents
• Allows for specific description of the specialized nature
of APPs APP Credentialing Committee
• As scope of practice/independence increases, makes
sense to have APP-focused credentialing committee
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Hospital’s Duty to Ensure Proper
Collaboration/Supervision
• Risks in relying on physician for credentialing
– Hospitals have accreditation obligation to
credential APPs
– Collaborating/supervising physicians are generally
not neutral/independent regarding the APPs with
whom they work
– Hospitals exposed to liability for APPs
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Uncooperative APPs/Physicians
• Potential Problems
– Scope of Practice
• Misuse of APP services
• Permitting APP to act outside of scope
– Unprofessional behavior
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Uncooperative APPs/Physicians
• Potential Problems
– Negligent Credentialing
• Uncommon currently, but potential future issue for
hospital to be liable for negligently credentialing
APP
• Wellstar Health Sys. v. Green, 258 Ga. App. 86 (2002):
– Health System held liable for negligent
credentialing of nurse practitioner
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And What Are You Doing With
•
•
•
•
•
•
•
•
Acupuncturists/Oriental Medicine Practitioners
Chiropractors
Homeopathic Practitioners
Naturopathic Practitioners
Optometrists
Private “Rounding” Nurse
Registered Nurse First Assistants
Therapists (Physical/Respiratory/Massage/Etc.)
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Questions?
Catherine Ballard, Esq.,
Executive Director
The Quality Management
Consulting Group, Ltd.
and
Partner, Bricker & Eckler LLP
[email protected]/
[email protected]
614.227.4848/614.227.8806
© QMCG 2016