As the population ages, a growing number of older adults and their families could benefit from the wide range of services that Advanced Practice Registered Nurses, APRNs, especially the nation’s estimated 154,000 nurse practitioners (NPs), can deliver. These nurses have advanced degrees and are clinically prepared to provide much of the care coordination, disease management, and primary care that older adults need.
Yet federal regulations and, in many cases, state laws hamper NPs’ ability to exercise their full practice authority.
More than three- fifths of states require NPs to enter into a collaborative agreement with a physician in order to diagnose and treat patients. Federal regulations and, in some cases, hospital policies also prevent APRNs from engaging in such practices as ordering tests or medical equipment, admitting patients to a hospital, approving home health care, signing death certificates, or prescribing drugs, especially the controlled substances on which many older adults rely to manage pain or dementia.
Although these laws were originally put in place to protect patients, the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, cites a patchwork of restrictions related to reimbursement also hinders consumers’ access to APRN services. For example, NPs must seek physician approval before Medicare will agree to pay for home health services for their patients. The ACA added an additional requirement that physicians must certify beneficiaries’ eligibility for these services and for durable medical equipment. These inefficiencies can reduce the amount of time NPs spend with their patients and result in care delays, especially in remote settings.
“[S]tates may want to consider easing their scope of practice restrictions and modifying their reimbursement policies to encourage greater NP involvement in the provision of primary care.”
−National Governors Association, 2012
In 2012, the National Governors Association recommended that states ease their scope- of-practice laws and retool reimbursement policies to expand access to NP-delivered primary care. In March 2014, the Federal Trade Commission added its voice to calls for reform. The agency characterized requiring APRNs to obtain a contractual agreement with a physician in order to practice “anti- competitive,” and urged states to change their rules.
Policies That Could Improve Access to Care for Older Adults
In 2008, the National Council of State Boards of Nursing (NCSBN) adopted
a model that allows for full APRN practice authority. The Consensus Model for the Regulation of APRN Licensure, Certification, Education & Accreditation was developed
by 23 nursing organizations that agreed to ensure access to affordable, high- quality LTSS for the growing population of older adults, policymakers and service providers can:
• Expand effective and innovative programs that use nurses to improve care for older adults and support their caregivers
• Make access to the Program of All-Inclusive Care for the Elderly (PACE) a mandatory state Medicaid benefit, and consider legislation that would increase the flexibility of PACE to provide services
• Encourage regulators to provide support to nursing homes engaged in “culture change” and other efforts to improve the quality of institutional care
• Encourage CMS to require staff at long- term care facilities to have more education related to caring for older adults and culture change
• Support continued funding for the Graduate Nurse Education Demonstration program
Numerous studies showing that NPs provide care that is equivalent to and sometimes better than the care provided by primary care physicians. Consumers with chronic diseases may also gain an additional benefit from NP care. A study published by the Centers for Disease Control and Prevention in April 2014 shows that NPs and physician assistants are more likely than physicians to educate their patients on how to manage chronic conditions.
NCSBN has also assisted state boards of nursing in adopting the model. To see the progress of state legislation, visit https://www.ncsbn. org/5397.htm.
Scope-of-practice reform has also experienced setbacks. In September 2013, the Veterans Health Administration proposed granting full practice authority to its 6,000 APRNs, but momentum stalled when some lawmakers expressed opposition to the idea.
ARTICLE COMPLIMENTS OF:
ROBERT WOOD JOHNSON FOUNDATION
EXECUTIVE EDITOR: Mary joan D. Ladden, PhD, RN, FAAN,
senior program officer, Robert Wood Johnson Foundation
SCHOOL OF NURSING, THE GEORGE WASHINGTON UNIVERSITY
The George Washington University Project Team
Source: Maria Schiff, The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care (Washington, DC: National Governors Association Center for Best Practices, 2012).
PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR:
Ellen T. Kurtzman, MPH, RN, FAAN, assistant research professor, School of Nursing
DEAN: Jean Johnson, RN-C, PhD, FAAN, School of Nursing