The Ohio Legislature is considering a bill to allow NPs to prescribe schedule II controlled substances. HB 206 was introduced at the request of the Ohio Association of Advanced Practice Nurses (OAAPN), said Lori Herf, lobbyist for the OAAPN. The bill was assigned to the House Health Committee for consideration in late September.

Primary sponsors are Rep. Barbara Boyd, chairwoman of the House Health Committee, and Rep. Scott Oelslager, who also sits on the committee. The bill had several hearings prior to that committee assignment. As a result of that testimony, an amendment was offered to prohibit NPs from prescribing schedule II controlled substances in convenient care clinics.

"The Ohio State Medical Association [OSMA] made that their primary issue in committee, but apparently may still oppose the bill," Herf said. The OSMA requested a provision to specify the locations where NPs could prescribe the drugs (hospitals and hospice care).

"What we have to understand is that there is inevitably going to be health care reform nationally, and when you have that kind of expansion, we must change the way we do business in the healthcare community," Boyd told MedCityNews.com. Boyd said she planned to get the bill out of her committee "as soon as possible," and predicted that bipartisan support was likely.

Herf said that passage of the bill would help NPs to more effectively manage a number of patient situations. "It will improve patient access, facilitate management of children with ADHD and promote therapeutic rest. It may decrease the need for obstetric intervention. It will also promote comfort at the end of life. Passage of the bill will improve patient safety because it decreases the need for verbal orders, facilitates patient access and improves patient outcomes."

• The requirement for a physician to be on site 20% of the time is reduced to 10%.
• An alternative practice site may be up to 75 miles from the primary practice site, an increase from 60 miles.
• The physician-NP supervisory ratio increases from 3:1 to 4:1.
• Chart review may be done electronically from a remote location.
• NPs and PAs can now write prescriptions for controlled substances lasting up to 90 days, an increase from 30 days.
• A waiver process can be used to increase the practice ratio to 6:1, to modify or eliminate the mileage limitation, or to modify other elements of the on-site practice requirements, provided that a means for off-site collaboration and communication is still provided.

The Nevada Interscholastic Athletic Association (NIAA) recently announced its intention to stop recognizing sports physicals performed by NPs and PAs. The change in regulation is scheduled to take effect in spring 2010. According to the NIAA's interpretation of Nevada statute, the only acceptable signatures will be those of physicians and homeopathic physicians.

NIAA executive director Eddie Bonine wrote a letter to Nevada schools to inform them of the change: "In light of difficulties this past practice has presented as to fall 2009 clearance, I am authorizing recognition of [nurse practitioners and physician assistants] to administer physicals for the 2009-2010 fall participation season only."

The NIAA met in September in Las Vegas and discussed this issue. The Special Practice Group (SPG), an advanced practice nursing group of the Nevada Nurses Association, sought volunteers to attend and speak on behalf of NPs.

"There is a strong need for us to step up here; this will affect us professionally and have a profound impact on our patients," said Tomas Walker, cochairman of the SPG. "Most of us have routinely done this work, and in many circumstances we were the only ones available to provide these services."

Walker said he has performed school and sports physicals since he started practicing as an NP in 1996. "There was never an issue. In the family practices I worked in, the NPs always did the school physicals. The school board in one rural district always contacted us directly to set up a couple of physical days so we could get them all done."

Walker believes the rule change was simply an oversight. "Frankly I don't see it standing." With the deficit in primary care in Nevada, removing NPs' ability to perform sports physicals creates an untenable demand, he said.

According to Diane McGinnis, NP, who attended the NIAA meeting, special arrangements were made to ensure that the NPs and chiropractors in attendance could speak. "One of the NPs from the health department testified that she does athletic participation physicals as part of her position at the health department," she said. Other testimony provided information about the many physicals NPs have safely performed. Many other providers testified that NPs perform these physicals safely, and sometimes are the only providers in a county to perform them.

Bonine said during the meeting that the board would consider using an expedited emergency procedure it can follow to make changes to regulations. Otherwise, a change could take more than a year to implement. He told the NPs that if they had patients to see that day for physicals, they should still see them.

"The executive director of the board also asked NPs to get the word out to the various state representatives and senators that we were looking for expedited approval and to be expecting the request," McGinnis told ADVANCE. "This is where we as NPs must step up to the plate and make a grassroots effort to inform our (and everyone else's) state assemblypersons and state senators what needs to be done ASAP!"

McGinnis also said that several of the testifying NPs volunteered to be members of the NIAA's medical provider advisory committee and to help expedite the changes in regulation.

The American Academy of Nurse Practitioners (AANP) Foundation has announced $111,000 in offerings available for nurse practitioner educational scholarships and project grants through the AANP Foundation Scholarship & Grant Program 2009 funding cycle. A noteworthy addition to the 2009 funding cycle is a $15,000 grant for women's heart health, the largest offering made by the program to date.

Complete details related to the AANP Foundation Scholarship & Grant Program, including a full list of offerings, eligibility requirements, application materials and deadlines, are available at www.aanpfoundation.org/scholarshipandgrantprograms. Application deadline is Oct. 21.

Nurse practitioners in retail health settings are now providing more services to their patients. Three clinic operators recently expanded their services: MinuteClinic added a rapid test to diagnose conjunctivitis, RediClinic added a smoking cessation program, and Take Care clinics added nebulizer treatments for patients who are in acute respiratory distress.

In a press release about MinuteClinic's conjunctivitis test, Donna Haugland, NP, chief nursing officer for MinuteClinic, said the offering "helps prevent the overuse of antibiotics and can lead to prescription savings."

At press time, MinuteClinic was expected to roll out acne care as a new service in the fall.

RediClinic's smoking cessation program, a four-visit service called Stop Smoking for Good, offers nicotine replacement and non-nicotine plan choices. Patients can also test their "real" lung age. As part of the program, NPs provide physicals and counseling as well as educational materials.

Take Care's nebulizer treatments are available to patients 2 years and older, when the NP deems the treatment necessary. Patients can also receive prescriptions for nebulizers that can be filled at the patient's pharmacy. In addition, NPs offer demonstration and education about the use of nebulizers and inhalers as needed.

These new services bring more healthcare options to patients, but clinic operators should be wary of the cost of these new services, noted Tom Charland, CEO of Merchant Medicine, in a Modern Medicine interview.

"The fact that these operators are still trying to figure out the right mix of services tells you something," he was quoted as saying. The "doc in a box" concept died in the 1980s, he said, because the clinics added new services to the point where their fixed costs were too high to sustain.

Bills that sought to remove collaborating physician requirements in New York recently stalled in the higher education committees in each chamber. Stephen Ferrara, NP, told ADVANCE that members of the New York Nurse Practitioner Association met with representatives of the Assembly and Senate to talk about the legislation and to garner their support and co-sponsorship for A765 and S2948.

"Each meeting we have is an opportunity to talk about NP practice and how statutory collaboration impedes access to care in this state," he said. "There are enormous workforce distribution imbalances in New York, and many rural areas cannot secure a health care provider for their community. For nurse practitioner practice owners, the requirement of a collaborative agreement costs time and money [because] a physician [has to] cosign an arbitrary number of charts, which is a poor allocation of the physician's time and has no evidence to support enhanced quality."

Although the bills did not get out of committee, Ferrara believes the meetings were helpful and he remains hopeful that the legislation will succeed in a future session.

Current New York law, which requires physicians to review a percentage of NP patient charts quarterly, can limit patient access to care and NPs' ability to work. If a physician collaborator dies, retires, moves away or otherwise ends the collaborative agreement, the NP must immediately stop seeing patients.

Keith Sutton, a New York NP, expressed frustration that the bill was tabled. He explained that through communication with members of the Legislature, he learned that only items affecting the state's budget were being considered.

"But what do you think is a huge public issue in terms of budget? Healthcare," he declared. "I think this [bill] is something huge that could save a lot of healthcare dollars in New York State."

Earlier this summer, 15 nurse practitioners and physician assistants from around the country met in Chicago to engage in groundbreaking discussion during the Digestive Diseases Week conference.  The roundtable discussion marked the first time NPs and PAs in the field of gastroenterology came together to discuss the findings of the UC: NORMAL (Ulcerative Colitis: New Observations on Remission Management and Lifestyle) surveys sponsored by Shire and their implications to the field, including how PAs can help fill the communication gap between physicians and patients with ulcerative colitis (UC).   

The objective of the surveys was to understand how UC affects patients' lives, including definitions of what's normal, patients' threshold for letting the disease disrupt life and how patients manage their condition.

In addition to the survey findings, participants also discussed the relationships among allied healthcare partners, including how they work together to treat patients with UC and outstanding resources to improve UC patient care.

The first two UC: NORMAL survey key findings discussed during the roundtable addressed UC patients' tendency to underreport flares to physicians and the psychological toll of the disease, including patients' willingness to accept flare-ups as "normal."  According to the surveys:

• UC patients reported an average of eight flare-ups per year yet only discussed an average of five of those with their physician.
• Gastroenterologists reported that a "typical" number of flare-ups per year on average is three among all patients (two flare-ups if condition is mild; four if condition is moderate; five if condition is severe).
• Four out of five (81%) patients said they consider the number of flare-ups they experience to be "normal" for their condition.
• 62% of patients believed that even more flares than they currently experienced would also be "normal."

The following two key findings focused on patients' and physicians' views on the impact of UC and the gaps that exist in these perceptions.  According to the surveys:

• Eighty-four percent of patients said going to the bathroom a lot has become a normal part of their life, while physicians estimated this is true for 52% of their patients.
• Seventy-three percent of patients said not feeling well has become a normal part of life, while physicians estimated this is true for only 37% of patients.

While many in attendance weren't surprised by these findings, they were in agreement that their positions allowed them to spend more time with patients, discussing flares and addressing the psychosocial issues experienced by UC patients and the need to better help patients manage their UC still exists.

The final two key findings discussed focused on patients' nonadherence to medication and the relationships between nonadherent patients and their physicians.  According to the surveys:

• Only about half of patients on 5-ASAs say they are fully compliant when taking their medications:
• -- Fifty percent strongly agree that they always take their medication as prescribed
• -- Fifty-four percent report having taken all the medication they were prescribed to take over the previous seven days
• -- Twenty-one percent report having taken just half or less of their prescribed medication
• -- The most common reasons cited by patients for poor adherence to 5-ASA medications included "forgot, try to cut back on medication when able, had been feeling well, forgot to carry medication while away from home, find it difficult to take so much medication and find it difficult to coordinate with schedules."
• Seventy-six percent of patients who weren't taking medication, but said they were supposed to, said they didn't schedule regular doctor visits.

Roundtable participants were in agreement that adherence is an issue among patients and expressed the need for educational materials that explain remission and the reasons patients should be adherent, as well as tools to help patients to remember to take their medication.  The roundtable served as a reminder of the role all healthcare practitioners play in building and maintaining relationships with patients to ensure proper care.

Following the discussion of the UC: NORMAL key findings, roundtable participants agreed on the need for a similar series of surveys among NPs, PAs, GIs and patients.  Participants felt the second series of surveys would be beneficial to better educate all parties on the perceptions of allied healthcare partners and the role of NPs and PAs in the treatment of UC and the positive treatment outcomes they can help foster.

Results of the Shire sponsored surveys should be available in early 2010.

Information provided by representatives of Shire Pharmaceuticals

• NP prescriptive authority will be shifted to the BON. The Board of Medicine previously maintained the exclusionary formulary for prescriptive authority. No physician oversight will be necessary; "appropriate relationships" are required.
• Global signature authority on many state forms (workers' compensation, department of health, department of human services, department of education, physical examination within scope of practice)
• Inclusion of NPs as primary care providers on insurance provider panels
• A requirement for graduate-level education as well as national certification to be recognized by the BON as an NP. The current law requires one or the other; now, both will be required for prescriptive authority.

"The healthcare community often places the most emphasis on immunizations for very young and very old patients," NPHF president Phyllis Zimmer, NP, said in a press release. "We need to make immunization for adolescents a priority as well."

Major obstacles to proper and timely immunization include lack of access to education and services, lack of health insurance coverage, practice barriers and missed opportunities, cultural and religious beliefs, and need for parental consent.

The NPHF recommends that healthcare providers raise awareness about the need for adolescent immunizations among 11- to 12-year-olds and their parents or guardians. The full document is available here.

Fast Facts About Adolescent Immunization

• All adolescents require measles, mumps, rubella, tetanus and diphtheria immunizations. Some high-risk people will need flu and pneumococcal vaccinations.
• More than 8 million children and adolescents ages 2 to 18 have at least one medical condition placing them at high risk for complications of the flu.
• The majority of the estimated 80,000 new cases of hepatitis B reported each year are diagnosed in adolescents and young adults.
• Many adolescents will need "catch-up" vaccines for vaccinations previously missed, such as hepatitis B.

Source: National Foundation for Infectious Disease. "Facts about adolescent immunization." Available online at http://www.nfid.org/factsheets/adolncai.shtml. Accessed July 29, 2009.

Posted July 29, 2009

Montana
NP Restraint-of-Trade Case Settles

The long awaited trial for a restraint-of-trade lawsuit against a hospital and physician who refused to accept radiology orders from a nurse practitioner-owned clinic in Butte, Mont., ended with a settlement just days after the trial began.

Shari Healy, NP, owner of the former Gold Street Clinic in Butte, and Vicki Thuesen, NP, who worked at the clinic, filed the lawsuit after the physician director of radiology and pathology at nearby St. James Hospital refused to accept their referrals for imaging outside of routine x-rays because they did not have physician supervision. The radiologist filed complaints with the Board of Medical Examiners charging that the NPs were "practicing medicine." These were dismissed. Various factors resulting from the restraint of trade forced the NPs to close the clinic in 2008.

After an 8-month delay requested by the hospital and physician defendants, the trial finally made it to court on June 1. Thuesen and Healy were prepared with expert witnesses and testimony detailing the damages caused by the restraint of trade. After just 4 days, the parties settled.

"It settled very suddenly," Thuesen told ADVANCE for Nurse Practitioners in a telephone interview. She explained that the trial was scheduled to run for 3 weeks and that the judge asked for the case to be settled on the fourth day of testimony.

"We're really happy that the case is closed and behind us," Thuesen said about the settlement.

Under the terms of the agreement, Thuesen and Healy are unable to disclose any details about it. Thuesen said she and her former partner also are unable to comment on their feelings about the contents of the settlement agreement. The NPs' lawyer, Devlan Geddes, echoed their statements: "My clients are happy to have the matter behind them."

Thuesen has relocated to Missoula and practices at a university health clinic near her home. When she isn't working in the clinic, she works for the Montana Migrant Council, a federally funded program that provides healthcare to migrant agricultural workers from countries such as South America, Mexico and Central America. Healy teaches at Gonzaga University and practices part time providing family healthcare services in the Butte area.

Both NPs are now able to submit radiology orders to St. James Hospital. As soon as Gold Street Clinic closed and she was no longer in Butte, Thuesen was "able to order everything I wanted as an independent nurse practitioner." The same proved to be true for Healy, who now works with a pediatrician and orders all services at St. James as an independent NP.

Thuesen's advice to any nurse practitioner who experiences restraint of trade is clear: "Don't back down, don't allow it, standup for our rights, and pursue anyone trying to block our practice as independent nurse practitioners if it's allowed by our states.

"It was a hard battle, but you've gotta hang in there, as rough as it is," Theusen said. "It's important for all of us."

Posted July 29, 2009

National
AANP Conference Draws Record Crowd

A tornado touched down in Nashville in June, along with 4,500 nurse practitioners who attended the 24th annual conference of the American Academy of Nurse Practitioners (AANP).

This year's conference drew the largest number of attendees at any nurse practitioner meeting. Thousands of nurse practitioners packed an enormous ballroom on opening day to meet AANP's board and hear opening remarks by director of health policy Jan Towers, NP.

Towers kicked off the conference by calling for each attendee to contact his or her congressional representatives about the need to include NPs in several important healthcare bills being considered on Capitol Hill, including The Healthy Americans Act, The Independence at Home Act, The Preserving Patient Access to Primary Care Act and a bill supporting nurse-managed health clinics. If all of these bills were to pass, Towers noted, the bill would be $1.7 trillion. Of course, many of the bills will be modified, with pieces "shaved off."

"We have to be sure they don't shave us," Towers emphasized. "We're trying to get our heads under the tent wherever we can." To get involved, visit www.aanp.org and click on "AANP Advocacy Center" to contact your federal lawmakers.

The doctorate of nursing practice degree continues to be a controversial topic, and this was evident in various sessions. NPs still have many questions. For one, attendees had concerns about the fact that the DNP is a clinical as well as a nonclinical doctorate, depending on the track the student takes. Attendees also asked questions about salary and whether current NPs will be grandfathered. Towers assured the audience that the clinical doctorate will only be earned by people who are nurses or become nurses in the process. The DNP wasn't designed to increase NP salaries, she explained, and yes, NPs who are current with certifications and licenses will be grandfathered.

Towers expressed strong sentiment against the first exam for DNP graduates, which was administered by the Council for the Advancement of Comprehensive Care last fall. Towers' statements drew loud support from session attendees.

At the membership meeting on the second day, AANP announced its state NP advocate awards and its 47 new fellows. AANP's new CEO, Timothy Knettler, spoke to the membership for the first time since succeeding Judith Dempster, NP. Knettler asked the attendees to envision the future of the NP role: "What would healthcare look like with double the number of NPs?"

Several first-time conference attendees shared their experiences on our Web site. Read their entries on the ADVANCE Voice blogs at http://community.advanceweb.com/blogs/np_1/default.aspx.

The 25th annual AANP conference will take place June 23-27, 2010, in Phoenix.

Posted July 29, 2009

Florida
Controlled Substance Bill Stalls

For the 16^th consecutive year, the Florida Legislature stalled a bill to award controlled substances (CS) prescribing rights to nurse practitioners. Florida Nurse Practitioner Network president Chris Saslo, NP, told ADVANCE that despite the strength of a Senate interim report providing evidence of the need for CS prescribing rights, the quest was not completed.

In fact, the CS prescribing bill did not get scheduled for a committee hearing and therefore was not considered by either the House or Senate. But there was a bright spot. A drug diversion bill designed to reduce narcotic "pill mills" and improve CS prescription tracking passed and was signed into law by Gov. Charlie Crist. This may help allay some lawmakers' fears about considering CS legislation for NPs next year, Saslo said.

"The hope is that with this in place, the comfort of having NPs take on the role [that] they have in 48 other states [will lead to] less opposition and more support," Saslo said.

Posted July 29, 2009

California
Bill Would Expand NP Practice Three Ways

A bill that would expand nurse practitioner scope of practice in California is being considered in the Assembly. Senate Bill 294, which was scheduled for final hearing June 30, would allow NPs in California to sign disability certification, order durable medical equipment and order in-home care.

"The best part about this bill . is that we have worked closely with the California Medical Association (CMA) to develop language we felt would offer Californians better access to quality health care. I think that was a critical component in the success of this bill," said Jill Olmstead, NP, president of the California Association of Nurse Practitioners (CANP). Olmstead explained that CANP put effort into other areas as well - by changing lobbying firms, performing more outreach and collaborating with other outside healthcare agencies.

"Someday we'd like to see the California nurse practitioners take a broader role in the state's health care system," Olmstead said, "so we have to take small steps forward so we can make that big leap in the future."

Olmstead is pleased that California NPs have been able to remain under the auspices of the Board of Nursing, especially because CMA challenged that issue. "A resolution was proposed in the CMA House of Delegates earlier this year seeking to move nurse practitioners within the Board of Medicine, but with our lobbying efforts, we will continue to forge improved working relationships with CMA."

Olmstead believes Senate Bill 294 will open doors to future opportunities for NPs. "If anything, it's an educational process, which is a challenge with any organization's leadership. Now that term limits have changed in the Legislature, there are new legislators coming in all the time that don't even know what a nurse practitioner is."

CANP grassroots efforts included an annual lobby day, outreach to membership and a needs assessment survey of the general membership of CANP to drive decisions about what type legislation was most important to the membership.

Posted July 29, 2009

Alaska
Change Allows NPs to Diagnose Autism

A change has been made in regulations for NP practice in Alaska that will benefit Alaska's students: NPs will now be allowed by the state to diagnose autism for Alaska schools.

Art Arnold, director of special education for the Alaska State Board of Education and Early Development, explained that Alaska's Governor's Council on Disabilities and Special Education created an ad hoc committee that has been studying autism issues in the state for the last 5 years.

"Though we're a very vast state we have very few resources and specifically physicians who are capable of making those kinds of diagnoses for kids," Arnold said. Prior to this change, only diagnoses by physicians and psychologists were accepted.

"Based on the recommendations of the physicians in the state who were responsible for making the diagnoses, and the governor's council along with the autism ad hoc committee, we received a recommendation to move toward allowing nurse practitioners to be authorized to make those diagnoses," Arnold said. Many of the public comments endorsed the recommendations. The change was made in June.

Arnold said that children had been waiting up to a year and a half to receive a diagnosis because of a lack of providers available to diagnose them. "Having a nurse practitioner be able to make those calls would be helpful to families and kids out there," said Arnold.

"We do expect somewhat of an increase of diagnosis of [autism]," Arnold said, but that it would simply mean that children who needed the diagnoses were receiving the necessary care.

"It was really just a clarification because NPs have complete independent practice in Alaska," said Lois Rockcastle, NP, Alaska representative for the American College of Nurse Practitioners. Rockcastle said the change wasn't statutory in any way - it simply brought the Board of Education's processes in line with current statute.

NPs who are certified by the state as pediatric, family or family psychiatric-mental health NPs may make the diagnosis to establish students' eligibility for special education services. Rockcastle noted that prior to the change, diagnoses of autism hadn't been accepted by the schools because they had been made by nurse practitioners. This prevented students from receiving special ed services.

Posted June 29, 2009

National
Federal Legislation Requires Quick NP Action
Nurse practitioners would get a significant boost from legislation now pending in Congress. U.S. Rep Allyson Schwartz (D-Pa.) and Sens. Maria Cantwell (D-Wash.) and Susan Collins (R-Maine) recently introduced the "Preserving Patient Access to Primary Care Act of 2009" (H.R. 2350/S. 1174) to address the shortage of primary care providers. The bill would create scholarships and loans for primary care providers who serve in critical shortage areas and support an interdisciplinary "medical home" model in which many types of providers would be able to practice collaboratively and to the full extent of their education and licensure.

The bill aims to increase primary care access for patients and includes nurse practitioners as leaders of patient-centered medical homes. Read the full text of the bill here.

At press time, the bill was being reviewed by several committees and no formal testimony had been scheduled. "This has the potential to be monumental legislation for our nation," wrote Stephen Ferrara, NP, on his blog, A Nurse Practitioner's View. He also pointed out that many physician groups are supporting this bill, but warned that "the American Academy of Family Practice is begrudgingly 'putting up' with the inclusion of NPs."

"These guys continue to play the turf war and it is getting so very tired," Ferrara wrote. "Nurse practitioners want to partner and collaborate with physicians."

The Patient Access to Primary Care Act defines a primary care provider as a physician or "(A) a nurse practitioner; or (B) a physician assistant practicing as a member of a physician-directed or nurse-practitioner-directed team; who provides first contact, continuous, and comprehensive care to patients."

Nurse practitioner leaders have expressed hopes that the term "medical home" will be changed to "healthcare home." Loretta Ford, NP, cofounder of the NP role, remarked similarly when she spoke with ADVANCE in May. "I don't think we're going to be part of a medical home, we're going to be part of a health home."

National nurse practitioner organizations are working collaboratively in Washington under an umbrella called the NP Roundtable. This coalition brings together the National Association of Pediatric Nurse Practitioners (NAPNAP), the American College of Nurse Practitioners, the American Academy of Nurse Practitioners and the National Organization of Nurse Practitioner Faculties.

"The NP Roundtable worked tirelessly with staff to influence the language of H.R. Bill 2350," explained Ann Sheehan, NP health policy chairwoman for NAPNAP. The NP Roundtable issued a call to action to its members in May, asking them send letters of thanks to bill sponsors and to ask other members to consider cosponsoring the bill if they had not already done so. These letters to Congress included information about how this legislation would affect NP practice.

"To serve the full U.S. population, every provider must work to the full legal scope of practice. Barriers to full NP practice exist in many bills federally and in state health care reform," Sheehan told ADVANCE.

The NP Roundtable's goal is to consistently convey the message that nurse practitioners are proficient providers and care coordinators in healthcare homes, that they are qualified to lead healthcare homes, and that they are qualified to provide direct health care, make appropriate referrals and to advocate for children, families and vulnerable populations.

Sheehan listed several hurdles that NPs might experience in relation to this bill. The following challenges make constant contact with legislators all the more urgent:

• Misunderstanding of the Institute of Medicine's definition of primary care, which states that primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community. This definition is provider-inclusive and acceptable to NPs.
• Use of physician-exclusive language in all legislation and health policy. This is true of medical home legislation as well as other health care reform proposals. The NP Roundtable is advocating for the use of terms such as "healthcare provider" or "clinician" or simply listing providers by their profession.
• Instances in which NPs cannot practice to the full extent of their education, certification and licensure. Safety nets already are in place to regulate the practice of nurse practitioners in the same way there are safety nets to regulate the practice of physicians, Sheehan noted.
• Barriers to patients' ability to choose NPs as providers if exclusive physician-focused language is passed.

Nurse practitioners should be eligible to lead medical homes, Sheehan said, noting that 14 states already have no requirement for physician supervision. She added that the goal of the APRN Consensus Model is for NPs to be licensed independent providers in all states. Federal legislation that is physician-focused will create barriers to NPs' ability to provide high-quality primary care consistent with the standards for the medical home.

"NPs will definitely end up providing care within the healthcare/medical home model if this legislation passes," Sheehan said. "Without provider-inclusive language, there is the danger that NPs will be invisible and not directly receive reimbursement for their services in this type of reimbursement system."

Any legislation that creates a medical home benefit that authorizes demonstration programs, revises reimbursement structures for primary care or sets incentives for participation in medical homes or coordinated primary care practices must be applicable to nurse practitioners.

Some states, such as Minnesota, have passed legislation that uses the term "healthcare home," not "medical home." NAPNAP's recent position statement uses the term "healthcare/medical home." However, the accepted term for the last two legislative sessions has been "medical home." The original concept of medical home was developed by pediatricians many years ago for providing comprehensive care to children with special needs, according to NAPNAP president Linda Lindeke, NP. The concept has evolved over time to other terminology such as "patient-centered medical home," a term typically used by internal medicine groups. The NP Roundtable has been collaborating with a large and growing organization called the Patient-Centered Primary Care Collaborative (PCPCC; www.pcpcc.net). A result of that collaboration is an extensive position paper by the American College of Physicians about NP practice that has been helpful in lobbying Congress for inclusive language.

"NPs must be aware that there has never been a time when their support of their professional organization of choice was more important," Lindeke told ADVANCE. "Nurses are working collaboratively in Washington as never before, and the stakes have never been higher."

In many bills, the concept of the medical home is inclusive of all health care. Because it is so broadly defined, NPs must be positioned as autonomous providers with full access to leadership roles and reimbursement. The opportunities, challenges and risks are considerable, and NPs are urged to respond to all calls for their involvement during this unprecedented time of reform. The evidence that NPs are safe, effective and well-accepted by the public is plentiful. However, interprofessional turf issues may be at an all-time high. The voice of each nurse practitioner is essential. Contact your lawmakers today!

Posted June 29, 2009

Colorado
NPs See Success at Sunset Review
During sunset review of the nurse practice act in Colorado, the Colorado Nursing Association (CNA) and nurse practitioner groups achieved passage of a law that increases prescriptive and practice authority. Last year, the Department of Regulatory Agencies (DORA) began examining the nurse practice act and spoke with stakeholders such as nursing groups and the Colorado Hospital Association to inform their decision about any changes. The CNA spoke with NPs and RNs for feedback, and the biggest area of concern was advanced practice regulations.

Existing Colorado law requires a written collaborative agreement with a physician and, after getting input, CNA came to the conclusion that "this really is a barrier to care, and it doesn't ensure safety," explained Tay Kopanos, NP, legislative chairwoman for CNA. "While it was set up a decade and a half ago to ensure access and safety, it's now a barrier."

NPs cited specific barriers such as difficulty finding physicians to participate in agreements, excessive fees and restrictions.

CNA reported back to DORA and recommended removing the collaborative agreement requirement. CNA provided documentation supporting the recommendation. Physician groups also had an opportunity to submit comments, and they proposed a more rigid, defined model.

Neither group was happy, so DORA recommended that the two entities get together to work out a compromise. DORA obtained a grant from the Colorado Health Foundation and facilitated seven meetings with five representatives from CNA (three NPs, one clinical nurse specialist and CNA executive director Fran Ricker) and five from the Colorado Medical Society (CMS). These discussions led to an agreement on several changes, including a softening of the collaboration requirement.

First, the parties agreed to a requirement for national certification starting in 2010 (the state currently does not require certification). Another change is the recognition of preceptor training by physicians or physician-NP teams (previously only a physician could precept) for the required 1,800-hour preceptorship. And finally, the current required career-long collaborative agreement with a physician will transition to a second 1,800-hour partnership called a "mentorship," which will be more loosely structured than the 1,800-hour preceptorship. Importantly, that mentorship can be with either a physician or a physician-NP team.

NPs in Colorado will also have to write and maintain an "articulated plan," which they can update yearly, specifying the five things they will do to ensure skills: maintain national certification, seek and maintain continuing education in pharmacology, maintain a quality assurance plan (such as peer chart review), maintain a system of consultation and referrals, and use recognized prescribing resources.

"As an NP's practice grows and matures, and new skills are obtained, the articulated plan will reflect these advancements and support expanded practice," Kopanos said. The NP will produce the plan if audited by the BON. One caveat is that for all existing NPs, a physician must verify that the NP has created an articulated plan. After verification, the NP will be able to prescribe independently.

Kopanos said nursing groups had hoped to allow an advanced practice nurse alone to precept and mentor NPs, but the group could not come to a consensus on that. "One of the ground rules for the facilitated discussions was that everything must be agreed by consensus. This meant that we did not get everything we'd wanted; but if something was agreed to in the work group, all parties would support it as we moved forward," she said. "That ultimately was a good dynamic."

CNA presented all recommendations to DORA, which passed them as an amendment to SB 239, the Nurse Practice Act. As a byproduct of this work, an advisory committee was created with representation from nursing and physician groups to talk about mutual concerns and make recommendations that are nonbinding but will inform future changes.

Kopanos emphasized that in addition to gaining increased prescriptive authority and practice autonomy, nurse practitioners in Colorado have garnered visibility in the community and more stakeholder support.

The statute changes go into effect in July 2010, and the next step is rulemaking, which NPs need to monitor and act on. "We have a long way to go . when we look at other states, like Texas, and compare the statute to the rules, we find their rules are more restrictive than the statute. Our next hurdle will be to ensure our new rules match the intent of the statute changes."

Posted June 29, 2009

Georgia
Bill Language Expanded to Include NPs
The Georgia Legislature recently passed a bill that will allow NPs to sign death certificates. It will also reduce the amount of supervision required for NP practice and allow role expansion of physician assistants. The new law also makes it illegal for an NP or PA to employ a physician as a delegating physician.

HB 509 sought to open the medical practice act to clean up some old language and remove some restrictions on physician assistants, said Karen Schwartz, NP, director of health policy for the United Advanced Practice Registered Nurses of GA (UAPRN). When the UAPRN read the bill, its leaders requested the addition of "nurse practitioner" to the wording about pronunciation of death.

"In some ways, I am concerned this legislation will hinder our ability to reach our objective next year," said Schwartz, referring to planned efforts to renew scope-of-practice expansion.

"Over this past session, our new lobbying team has done an extraordinary job to develop better relationships with the legislators - even past adversaries," Schwartz said. She said she hopes these efforts will help UAPRN achieve additional changes next year.

Posted June 29, 2009

National
Healthcare Reform a Focus at NAPNAP Meeting
SAN DIEGO - Healthcare reform was a primary focus of the annual conference of the National Association of Pediatric Nurse Practitioners (NAPNAP) held here in April. About 1,100 pediatric NPs attended the meeting, which featured enthusiastic discussion about issues ranging from breastfeeding rights to the doctorate of nursing practice.

Amidst many timely pediatric health issues, healthcare reform - specifically the opportunities that the reform movement will provide for NPs - attracted the most interest and discussion. Courtney Yohe, a government relations specialist with NAPNAP lobbying firm Arnold and Porter, could barely conceal her excitement about historic opportunities to implement some type of universal healthcare coverage in the United States. "This is the time to be engaged," she urged.

NAPNAP offers nurse practitioners a portal to information and tools that increase understanding of pending federal legislation affecting NP practice and healthcare. Portal access is not limited to NAPNAP members. The organization's legislative action center, housed at www.napnap.org under the advocacy tab, uses a program called Capwhiz to connect NPs directly to lawmakers.

In addition to clinical and legislative sessions, pediatric NPs had the opportunity to hear from the founder of Positive Exposure, a nonprofit organization whose mission is to challenge the stigma of difference, particularly where genetic disorders are concerned (www.positiveexposure.org). Former fashion photographer Rick Guidotti established Positive Exposure after meeting a young woman with albinism. He found her beautiful, but she didn't agree . until he photographed her in a manner befitting a Vogue cover model. Since that day, Guidotti has photographed thousands of children and adults with genetic disorders in his quest to "celebrate the beauty and richness of human diversity." 

NAPNAP presented its most prestigious honor, the Henry K. Silver Award, to Abbey Alkon, NP, a member of the nursing faculty at the University of California in San Francisco, during the opening ceremony. The award honors the NAPNAP member who has made outstanding contributions to advancing the pediatric nurse practitioner role and improving children's health on a national or international level. At an awards breakfast during the conference, the association honored 41 NPs for outstanding service and practice innovations.

The 2010 NAPNAP conference will be held April 15 through 18 at the Hyatt Regency hotel in Chicago.

Posted May 28, 2009

Nevada
Trio of Bills Would Affect NPs
Three bills introduced in Nevada could affect NP job opportunities, employment contracts and authority to sign state forms.

The first bill, AB 495, removes the $350,000 cap on malpractice awards and removes caps on lawyers' fees. The awards cap was placed in 2004 under the Keep Our Doctors in Nevada initiative. AB 495 was introduced in response to a flood of high awards in the wake of a large-scale hepatitis C outbreak caused by negligent injection practices at a Las Vegas gastroenterologist's clinics.

"Higher malpractice premiums mean less chance [NPs] will be hired," said David Burgio, NP, cochairman of the Special Practice Group (SPG), an advanced practice nursing group of the Nevada Nurses Association. "The physician can just hire another physician and have them carry their own insurance rather than pay high premiums for us." Burgio said the group has been encouraging letter-writing to oppose the bill.

NPs in Nevada have been able to purchase malpractice insurance at reasonable rates, said Tomas Walker, NP, cochairman of the SPG. "Allowing that to change could seriously jeopardize our ability to continue to practice."

Walker works in an endocrinology specialty practice, and he estimates that only about a dozen endocrinology physicians, NPs and PAs provide this specialty care to 2 million people in the state. "So anything that potentially limits ours ability to provide care for our population must be evaluated and opposed if needed."

A second bill, AB 470, prohibits noncompete agreements for people who hold a professional license. In Nevada, noncompetes have mostly been used by a large HMO to prevent physicians from practicing too close to HMO-owned clinics when they leave the system, Walker explained. "Officially recognizing that noncompetes inhibit the fair practice and trade we are providing would benefit us professionally," he said. Walker believes this bill is even more controversial than AB 495, because the only populated areas of Nevada are Reno and Las Vegas. "Any restriction on professional practice in the form of a noncompete can easily result in a need to move, quit practice or change specialty."

"We don't have the option that physicians do of just opening our own practice outside of the area," Burgio noted. "I and my wife were adversely affected by a noncompete years ago, when the group we worked with fell apart."

Another bill, SB 249, would allow nurse practitioners to sign physical examination forms for taxi drivers, a task currently reserved for physicians. "The cost-effective, high-quality work we have provided speaks for itself; I see this more as a correction of an existing oversight," Walker commented. The Senate passed this bill. At press time, it was awaiting House action.

Walker noted that seeking NP authority for signing handicap placards is perhaps a more important goal, but with "political and financial realities what they are, this is an issue we can not address this year."

Posted May 28, 2009

Maine
NPs Earn Global Signature Rights
April brought welcome opportunity for nurse practitioners in Maine. The Legislature's joint Business, Research and Economic Development Committee recommended passage of a bill that would grant NPs the right to sign all medical documents. Maine NPs and their supporters testified before the committee in favor of LD 695, titled "An Act to Streamline Health Care Services in Maine by Allowing Certified Nurse Practitioners and Certified Nurse Midwives to Verify Medical Papers and Records."

The bill states that when a provision of law or rule requires a signature, certification, stamp, verification, affidavit or endorsement by a physician, "that requirement may be fulfilled by a certified nurse practitioner or a certified nurse midwife."

"This is wonderful news!" declared Valerie Fuller, president of the Maine Nurse Practitioner Association (MNPA). She told ADVANCE she considers passage of the bill likely.

Fuller said the bill will help streamline healthcare in the state. "It's huge for NPs who frequently deal with paperwork that says 'signature.' . It's going to alleviate a lot of the aggravation that patients have about seeing a nurse practitioner and having a form signed and then being told that the form can't be accepted - that they have to have a physician sign the form." Often, Fuller explains, these NPs work independently and spend unnecessary time locating a physician willing to sign the forms.

Fuller noted that the MNPA used a similar law passed in Rhode Island as a model for its global signature bill.

Posted May 28, 2009

National
Retail Health Operators Offer Free Care
RETAIL HEALTH NEWS: To offset the pain of healthcare benefit losses by U.S. residents who have lost their jobs, Take Care Health Systems recently made a significant announcement: Take Care clinics will offer free healthcare services to people who lost their jobs after March 31, 2009, and are uninsured as a result. Quest Diagnostics announced that it will offer free laboratory tests for some of these visits. The program applies to most services currently provided at Take Care Clinics, including routine treatment of respiratory illnesses, skin conditions and common episodic conditions, such as allergies.

Sandra Ryan, NP, Take Care's chief nurse practitioner officer, is featured in a video explaining the Take Care Recovery Plan. With the required paperwork, patients can access these services any time between 11 a.m. and 3 p.m., Monday through Friday. Certain treatments or services, such as physicals and vaccinations, are excluded from the offer. Take Care hopes that this program will help patients save money and help stem unnecessary visits to emergency departments.

In a separate effort to address rising healthcare costs and economic challenges, The Little Clinic is offering free health screenings and assessments for the remainder of 2009. The program will focus on core health issues such as nutrition, preventive medicine and wellness.

Lisa Loscalzo, executive vice president of business development for The Little Clinic, commented in a statement: "Our program is aimed at providing those important screenings and healthcare assessments that need to be performed throughout the year in order to monitor overall health. Because this program is free, The Little Clinic is helping to make sure good health can remain a focus for everyone." The Little Clinic will also supply handouts offering tips for healthy snacking, food portioning, reading labels, understanding a child's growth percentile, and managing blood pressure and cholesterol.

Posted May 28, 2009

National
NPHF Cosponsors Self-Care Training Program
To help healthcare providers equip patients to choose the correct over-the-counter medications, the Nurse Practitioner Healthcare Foundation (NPHF) is cosponsoring the OTC Advisor, a free online training tool that helps NPs offer the best counsel to patients using OTC medications and home diagnostic products.

The program consists of online modules that can be completed over time, and participants can receive up to 18.5 free continuing education credits. The modules cover OTC care for pain management, fever and cold symptoms, gastrointestinal disorders, skin disorders, popular herbal and dietary supplements, and use of home diagnostic products.

"Nurse practitioners focus on personalizing care to meet each patient's needs. The ability to answer questions about the wide array of OTC products requires a broad knowledge base of all of these products," said Phyllis Zimmer, NP, president of NPHF, in a statement. Zimmer hopes the tool will particularly help NPs in convenient care settings.

Posted May 28, 2009

National
NPWH Offers Free HPV Testing Toolkits
The National Association of Nurse Practitioners in Women's Health (NPWH) is offering free toolkits to help NPs effectively test for the human papilloma virus (HPV) - the cause of cervical cancer - as part of routine cervical cancer screening. The effort is part of the group's program titled "HPV Testing: Know it. Use it. Talk about it." The program is designed to help healthcare providers keep up with emerging standards of care in cervical cancer screening.

"Effective screening continues to be a critical part of cervical cancer prevention, and an HPV test along with a Pap test provide women age 30 and over with the best protection against this disease," said Susan Wysocki, NP, president and CEO of the NPWH, in a statement.

NPWH's toolkits evolved from the results of a survey the organization released last year. It showed that many women misunderstand facts about cervical cancer prevention and HPV. This was particularly true of women 30 and older, who are most at risk of developing cervical cancer. The HPV testing toolkits are available at www.npwh.org.

Wright is a family NP who established Wright and Associates Family Healthcare in 2007, which now employs three NPs. Wright is also an owner of Partners in Healthcare Education, a medical education company, for which she is a sought-after speaker on a wide range of healthcare topics. Wright is also a frequent contributor to ADVANCE for Nurse Practitioners.

Wright has also taken a leadership role in bringing together other entrepreneurial nurse practitioners to share information, provide support and get their issues on the radar of policymakers. In 2008, the group established itself as the NH Chamber of Entrepreneurial NPs.

"It is truly such an honor to be recognized in this manner," Wright told ADVANCE. "I never dreamed for a minute that I would be chosen with all of the amazing nurse practitioners in this state." Wright says she is grateful that she lives and works in New Hampshire, a state that recognizes nurse practitioners as important and essential members of the healthcare community.

"Being in a state like this allows all of us to know that with a little hard work, we can bang down the walls and doors which have been built for decades to limit the role," she said. "Awards like this, where you are recognized by your peers and colleagues, are the icing on the cake!"

Posted April 29, 2009

National
Results for DNP Exam Announced

Half of DNP graduates who sat for a generalist competency examination modeled after a physician licensure test earned passing scores, a rate that is being both heralded and scrutinized.

The voluntary examination, given by the American Board of Comprehensive Care (ABCC) Council for the Advancement of Comprehensive Care (CACC), was comparable in content to Step 3 of the U.S. Medical Licensing Examination. The ABCC exam for DNP graduates measured the same set of competencies and applied similar performance standards as the test administered to physicians as one component of qualifying for licensure.

Forty-five NPs took the exam, and 22 earned a passing score, said Mary Mundinger, outgoing dean of the Columbia University School of Nursing and a member of the ABCC. The examinees were all experienced NPs who had completed a DNP program. The passing score for this exam was the same as that of the Step 3 NBME exam, because "we tried to make it as clear as possible for any DNP passing this exam that [he or she was] meeting a standard that had been set for physicians in that final test," Mundinger said in an interview with ADVANCE. NBME will continue to work with ABCC to create each year's exam.

Mundinger said the ABCC was pleased by the 50% pass rate. She noted that MD test-takers have already taken Step 1 and Step 2, and their schools prepare them specifically for the exam. "We didn't think we'd get to 50% [in] the first year. So we're thrilled."

Mundinger believes the exam will foster a standardized clinical curriculum among DNP programs so that when graduates take the certification exam, they will demonstrate their comparability to physicians in primary care.

Many DNP test-takers ran out of time, she noted. With more preparation, "it won't be long before the pass rates are indistinguishable."

Mundinger explained that many current DNP programs have less clinical content because they don't have the faculty to support it. As DNP programs evolve, schools will be able to offer more. "It was easy for [Columbia] to establish a really high-level clinical program because we'd been developing faculty along those lines for many years and our medical school was deeply supportive," Mundinger said. "Those faculty have medical school appointments and they have admitting privileges to the hospital, so we had a really grounded cohort and environment in which to launch this program. Other schools that haven't been going along that path for the last few years have got to jump start a DNP program without the advanced clinical acumen of faculty."

Some NPs believe that taking a test originally designed for MD graduates is counterproductive to the advancement of the nurse practitioner role, but Mundinger disagrees. She says misperceptions about the examination are lingering. The test is designed especially for advanced practice nurses, she said, and it is voluntary. But she notes, "If we don't have an overlap of all of the competencies that are necessary for primary care, then it's a little difficult to say that insurance companies should list us, that they should pay us the same rate [and that] we should be advertised the same way if we can't show that comparability."

Mundinger worries that DNP graduates from programs with less clinical content will not do well on the ABCC exam. "They'll be ill served by the whole process" by taking the exam now, she said, because in time, curricula should be more standardized.

The American Association of Colleges of Nursing issued a statement in March regarding this exam, stating "AACN recognizes the doctor of nursing practice (DNP) as a degree that prepares graduates for many roles, and that DNP graduates may choose from many specialties in which to be certified. Comprehensive care certification is one option available to DNP graduates who wish to pursue this additional certification, but it is not appropriate or required for all DNP graduates." To view the statement, click here.

Posted April 29, 2009

National
Physician Group Publishes Monograph About NPs

The American College of Physicians (ACP) recently published a monograph that formalizes the organization's stance on the future of NPs in primary care. The ACP collaborated with NP advisers to write the monograph.

The paper acknowledges the growing shortage of primary care physicians and the growing need for nurse practitioners. "ACP leaders decided that it would be appropriate for the college to review its existing policy to reflect the current health care environment and the challenges facing the two professions," said Michael Barr, vice president of advocacy and improvement for ACP.

The ACP asked a group of nurse practitioner leaders to advise the development of the paper. Two meetings took place in 2008. "The dialogue proved extremely useful, as was follow-up via e-mail during the ensuing months," Barr said.

The monograph states seven policy positions, paraphrased here:

1. Physicians and NPs provide quality care, but they are trained differently, and sometimes physicians are more appropriate providers.

2. Collaboration (ongoing interdisciplinary communication about care) should exist among all health care disciplines.

3. Licensing and certification exams for NPs should be developed by the nursing discipline. ACP therefore opposes the use of Step 3 of the medical licensing exam for DNP testing by the American Board of Comprehensive Care.

4. Patient-centered medical home demonstration projects should include NP-led practices for evaluation against those led by physicians.

5. ACP advocates more research to identify the best model for collaboration, referral and comanagement of patients by NPs and physicians.

6. Opportunities for cross-discipline education and training should be embraced.

7. Workforce policy should ensure an adequate supply of physicians and NPs, yet it should realize that NPs cannot fully replace physicians.

Barr emphasized that he believes NPs and physicians should maximize communication and sharing of information, and that the paper does not address written collaborative agreements because requirements differ across states. The paper calls for collaborative agreements that have "a shared commitment to achieving positive patient outcomes, a mutual understanding of team members' roles, an agreement to practice within an individual's scope of practice and a mechanism for communication."

"Therefore," Barr said, "ACP favors the team-based model of health care and collaborative care. Our discussion with some NP leaders suggested that the majority of NPs also prefer this model. ACP does acknowledge the existing ability for NPs to practice independently in some states."

The full 18-page monograph is available to read online here.

Beth Partin, NP, legislative liaison to the Kentucky Coalition of Nurse Practitioners and Nurse Midwives, believes the paper is a step forward for collaboration between NPs and physicians.

"None of us live or practice in a vacuum, and we must interact with other healthcare professionals," she said. "What the ACP said has never been said before by any physician group, and in fact is in opposition to what many of their colleagues are currently saying."

"I was amazed when the ACP invited the nursing groups to the meeting last summer to discuss the issues and was further amazed when I read the report. While not all that we would wish, it is a positive step forward ... and that's how the battle is being won . one step at a time."

"I am a strong advocate for fully autonomous NP practice, and I work every day in Kentucky toward that end. I do believe it will come. It's just a frustratingly slow process," Partin said.

Posted April 29, 2009

National
MinuteClinic Makes Big Changes

RETAIL HEALTH NEWS: Retail health care operator MinuteClinic has been making big waves in the industry so far this year. In February, the company announced a high-profile partnership with Cleveland Clinic, one of the nation's largest hospitals. By the end of 2009, MinuteClinic plans to have nine clinic locations inside CVS stores with direct referral access to Cleveland Clinic, and each will have a medical director appointed by Cleveland Clinic Health System. The clinics will fully integrate their electronic medical record (EMR) systems with Cleveland Clinic's, so that all patients who have visited a MinuteClinic or the Cleveland Clinic will be able to access an integrated record at both locations. Patients will also have the option of sharing their records with other Cleveland Clinic-affiliated locations in northeast Ohio via MinuteClinic EMR.

"We see ourselves as part of the health care solution and part of working with other groups to make it happen," said Donna Haugland, chief nursing officer for MinuteClinic.

MinuteClinic is in talks with other health care organizations in Massachusetts and across the country about creating similar partnerships.

MinuteClinic made another big move recently by closing 90 of its clinics. The company cited a drop in demand as the reason for shutting 16% of its sites and stated that it plans to reopen those clinics as needed on a seasonal basis. Brent Burkhardt, a spokesperson for CVS, told ADVANCE that "A total of 460 clinics remain open 7 days a week year-round. . in many cases, weekend hours have been extended at these locations."

Tom Charland, CEO of Merchant Medicine, told CNN Money that the MinuteClinic closures marked the first time any large-scale seasonal closures had taken place in the convenient care industry. MinuteClinic is continuing to open new clinics in areas where the company hasn't yet penetrated the market.

Posted April 29, 2009

Florida
Bill Introduced for NP Rx Rights

For the 15^th consecutive year, a bill has been introduced in the Florida Legislature to allow nurse practitioners to prescribe controlled substances (CS). The chairman of the Senate health committee, Mike Bennett, decided to sponsor the bill this year.

To prepare for consideration of this bill, The Florida Senate met in December to discuss results of a legislative committee study of CS prescribing in the state. The report cites NP qualifications for CS prescribing and a lack of health care access for Florida citizens as reasons to allow NPs to prescribe controlled substances. (This information was reported in The Front Page section of our January issue.)

Lobbying days took place March 17 and 18 in Tallahassee. Susan Lynch, NP, legislative liaison for Florida Nurse Practitioner Network (FNPN), attended with a large group of advanced practice nurses.

"We have been making an impact," she told ADVANCE. "Several freshmen legislators who have not made up their mind yet have received, we think, over 1,000 emails . so it's working and people are paying attention to us."

Stefanie Coffey, NP, told the Miami Herald that her survey of 2,000 NPs, nurse midwives and nurse anesthetists found that they spend 8 hours a week on paperwork to get prescriptions for CS. "It's a turf battle," Coffey told the newspaper. As if to prove the point, Jeff Scott, the Florida Medical Association's director of legislative affairs, told the Miami Herald that nurse practitioners don't have as much training in pain medicine as doctors do. "It's not about money, it's about patient safety."

Lynch disagrees. "The Florida Medical Association and the Florida Legislature need to realize that their actions are directly contributing to the suffering of the citizens that they are obliged to help," she said. The volunteer medicine clinic and community health center where Lynch works serves Medicaid and Medicare patients, 80% of whom are uninsured. More patients are seeking care there every day. One of Lynch's patients had to stop treatment for severe rheumatoid arthritis and was without an anti-anxiety medication for 3 weeks because her insurance had run out.

"I see the patients the physicians are refusing to see because they have no health insurance, and I'm like many NPs across the state," Lynch said.

"The patients have been tossed aside because of a lack of insurance. They're being tossed aside and I'm not able to prescribe the necessary medications because of political gains in Tallahassee. This issue is about access to care. The physicians won't see them, I care about them, and I am prevented from stopping their suffering all because the FMA and the Florida Legislature have colluded to block this bill for 15 years."

The FNPN, in cooperation with the Coalition for Advanced Practice Nurses in Florida, will be retooling and developing its strategy within the next few months. Lynch encourages all NPs to be informed and involved. Sign up for action alerts on the legislative activity page of FNPN's Web site, www.fnpn.org.

"We will need every NP in the state to step up, step forward and be involved, both financially and through grassroots activity."

Posted March 30, 2009

National
Feds Designate NP as Unique Occupation

The nurse practitioner profession has finally been recognized as a unique occupation by the federal government. The Office of Management and Budget announced its 2010 Standard Occupational Classification (SOC) rulemaking in January. In the final document, nurse practitioners, nurse midwives and nurse anesthetists are each given an occupational designation separate from "registered nurse."

These revisions, the first made since 2000, are in response to nurse practitioners' requests that they be listed separately from other registered nurses. This is an important milestone for nurse practitioners because it further defines the uniqueness of advanced practice nursing. To read the SOC document, click here.

Mary Jo Goolsby, director of research and education for the American Academy of Nurse Practitioners, described how NPs were instrumental in bringing about this change: ". for several years, the Bureau of Labor Statistics has heard from individual NPs, as well as other APNs, concerned that our 'occupations' were not visible within the broader 'RN' classification." She also explained that AANP has advocated for this change wherever possible, such as partnering with a contractor to the Department of Labor to define the NP occupation.

All federal agencies use the SOC for statistical purposes when comparing and publishing occupational data. State and local agencies also use the SOC, so a common language is more likely to be used, and the NP role will become more visible among health care roles. Goolsby said she hopes that with time, the media will consider NPs when compiling data on the fastest growing or best careers for health care providers.

"It is a very positive change and one that has been in the works for a couple of years, so it's great that it is now in place," Goolsby said.

Posted March 30, 2009

National
Accreditation for NP-Run Organizations

The Accreditation Association for Ambulatory Health Care (AAAHC) has taken a step toward better health care access for patients. The association has begun accrediting nurse practitioner-run ambulatory organizations in states where NPs can practice independently.

"The Accreditation Association took this step in response to the growing number of rural clinics, college health centers and other organizations such as American Indian health clinics that are supervised by advanced practice nurses, often due to a shortage of physicians," said Roy C. Grekin, AAAHC medical director, in a press release. "This enables these organizations to undergo on-site surveys and earn AAAHC accreditation as a mark of the quality of care they offer these patients."

As of 2008, NPs can practice independently in 11 states and the District of Columbia. The 11 states are Alaska, Arizona, Idaho, Iowa, Maine, Montana, New Hampshire, New Mexico, Oregon, Washington and Wyoming.

Posted March 30, 2009

National
NP Elected President of AWHONN

The 23,000-member Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) elected Kim L. Armour, NP, as its 2009 president. Armour is a women's health nurse practitioner and a diagnostic medical sonographer specializing in fetal diagnostics. She is  manager of the Women's Subspecialty Center at Central DuPage Hospital in Winfield, Ill.

"I am very proud of my long-time involvement with AWHONN at the local, state and national levels. I look forward to continuing my role as president to further advance the success of AWHONN and the women and newborns we care for every day," Armour said in a press release.

Armour has been active in AWHONN since 1991 and is a nationally renowned speaker. She received the AWHONN National Award of Excellence for Clinical Practice in 2003. Other honors include the Ruggles Gates Fellowship for Scholarship at the University of Texas at Tyler's PhD program, the March of Dimes Jonas Salk Health Leadership Award, the United States Professional Nurse Trainorship Grant, and The Tom Williams, MD, Nursing & Patient Care Services Award for Volunteerism.

Posted March 30, 2009

National
CCA Enforces Standards

RETAIL HEALTH NEWS: The Convenient Care Association (CCA), which represents 95% of the retail health industry, announced that all of its member organizations meet the CCA's quality and safety standards.

The organization's board of directors adopted its quality and safety standards in March 2007 with input from national medical, nursing and accrediting organizations, as well as its clinical advisory board. All members must comply with the standards.

The CCA contracted with the Jefferson School of Population Health to administer the official member certification program because of its expertise in the evaluation of health policies and systems that improve the health of populations. This certification process marks the first time that a national third-party health care leader of Jefferson's expertise has confirmed that CCA members are meeting the retail health industry's 10 quality and safety standards.

The standards address such issues as monitoring quality at each clinic, encouraging patients to establish relationships with primary care providers, and establishing emergency response procedures. The standards are available at http://tinyurl.com/ccastandards.

"This certification is a true testament to the industry's continued commitment to work together to ensure quality standards are met for the greater good of individuals seeking health care services across the United States," said Sandra Ryan, chairwoman of the CCA Clinical Advisory Board, and chief nurse practitioner officer for Take Care Health Systems, in a press release. Other clinic operators will be following suit; RediClinic announced its certification in February.

Member clinics are required to use electronic health records, which positions them as health technology leaders. Electronic records are a primary reform goal for achieving increased health care efficiency under the Obama administration.

"The retail clinic industry is a trailblazer in the adoption of new technologies, such as electronic health records, that are enhancing continuity of care as well as contributing to the tracking and trending of healthcare outcomes," said David Nash, dean of the Jefferson School of Population Health, in a press release.

CCA members also follow established requirements for health care facilities and are held to strict criteria for credentialing providers, tracking patient satisfaction and referring patients to appropriate levels of care based on their conditions.

Posted March 30, 2009

National
Retail Study Doesn't Reflect 2008 Spike

RETAIL HEALTH NEWS: A survey by the Center for Studying Health System Change determined that 3.4 million U.S. families, or 2.3%, had used a retail clinic as of 2007. But the data don't reflect the spike in growth that occurred in 2008.

The survey, titled "Checking Up on Retail-Based Health Clinics: Is the Boom Ending?" also showed that 27% of families who used retail clinics had at least one uninsured member. Families who said they experienced delays in receiving health care and families with younger members were more likely to use retail health clinics.

"2007 was really the growth year," explained Tine Hansen-Turton, executive director of Convenient Care Association, in an article in the Orlando Business Journal.

Evidence shows that retail clinic use is not moderate anymore. A report published by Deloitte in 2008 included results of a poll that showed that 16% of American consumers had used a retail health clinic.

Posted March 2, 2009

National
RediClinic Closes Sites

RETAIL HEALTH NEWS: Houston-based convenient care clinic operator RediClinic closed sites in Wal-Mart stores in four of its markets, but the company is regrouping to forge on. The closures, which occurred in Georgia, Oklahoma, Virginia and Arkansas, accounted for 15 of 36 RediClinic sites.

Nurse practitioners employed at the clinics received little notice of the closures, much like at CheckUps Clinics, which closed all of its clinic locations early in 2008. RediClinic no longer operates clinics in Wal-Mart stores, but 21 of its clinics are still in operation in HEB supermarkets in Texas. The company cited economic reasons for the closures.

"That's sad news," Charisse Braxton, NP, former district manager for RediClinic's Atlanta, Arkansas and Oklahoma markets, told ADVANCE after the closures. "Hopefully the economy will start to turn around, because the need for these clinics still remains."

RediClinic is one of only seven retail health operators with more than 10 clinics. However, unlike some of the other larger chains (MinuteClinic, owned by CVS, and Take Care Health, owned by Walgreens), RediClinic is not owned by a retail store chain and therefore has a smaller financial safety net in a tough economy.

Katie Brazel, a RediClinic spokeswoman, told The Morning News of Northwest Arkansas that the clinic closures were not tied to Wal-Mart. Wal-Mart continues to partner with hospital systems to operate clinics inside its stores, so the retailer could potentially focus on those partnerships. Brazel also said that RediClinic plans to raise capital to ensure that its existing clinics can survive the stressed economy. "We are confident the model for convenient care clinics is a good one," she told the newspaper.

In an interview with ADVANCE, Brazel explained that "RediClinic has not ruled out returning to these markets or locating within Wal-Mart."

Posted March 2, 2009

Arkansas
Regulation Could Limit NP Practice

A regulation affecting collaborative practice is poised for further movement this year. Regulation 30 outlines several new requirements for practice by physicians and NPs who elect to form a collaborative practice in Arkansas.

NPs testified at two public hearings before the regulation was forwarded to the public health committee, explained Marilou Shreve-Doffin, NP, chairwoman of the Arkansas Nurses Association (ARNA) Advanced Practice Nurse Council. The first version of Regulation 30 required that all collaborating physicians live and work in Arkansas, limiting collaboration in cities that border other states. The second version allows collaborating physicians to be located in counties of states that border Arkansas. It requires a new form notifying the Arkansas State Medical Board (ASMB) of a collaborative agreement, as well as annual renewals of agreements regardless of changes. It requires extensive documentation of scope and protocols. The second revision also states that each physician must provide a copy of the quality assurance plan for any collaborative agreement.

And fine-tuning of this proposal is not complete. The ASMB continues to seek revisions that require physicians to review 10% of all NPs' patient charts and that require NPs to distribute detailed information to their patients about the collaborating physician. The ASMB adopted Regulation 30 in August 2008, and it is posted on the ASMB Web site with a notice that implementation of the regulation is delayed pending further input.

The Public Health Welfare and Labor Committee, comprising members of the Senate and House, heard testimony about the regulation in September 2008, according to Shreve-Doffin. Supportive testimony was presented by NPs and the ARNA. The ASMB, the medical society and a retired state representative who opposed Regulation 30 also spoke on the issue. In October 2008, the rules and regulations committee approved recommendations from the public health committee, and Regulation 30 was tabled because opinions still differed broadly.

On Oct. 6, 2008, Rep. Sandra Prater proposed to the Public Health Welfare and Labor Committee that a study be conducted to determine the effects of removing the collaborative agreement requirement. The results were presented to the committee in December 2008. The report found much of the state to be medically underserved and noted that health care outcomes were either unchanged or had improved in states that had eliminated a statutory requirement for a collaborative agreement between NPs and physicians.

Arkansas was rated 48th by the Commonwealth Fund's 2007 "National Scorecard on Health Status." Placing further bureaucratic restrictions on providers will decrease access to care in a time when increased access should be the goal, Shreve-Doffin told ADVANCE earlier this year.

Posted March 2, 2009

Pennsylvania
Changes Could Improve Patient Access

A 30-day comment period for proposed practice regulations in Pennsylvania ended recently, but changes appear to be months away. The creation of these regulations marks the first time in 8 years that NPs in Pennsylvania will update practice parameters since becoming solely regulated by the Board of Nursing (BON) in 2000.

Act 48, signed into law by Gov. Ed Rendell in 2007, states that NPs can practice independently and can order home health care, but current regulations prevent NPs from being able to practice according to the act. The proposed changes will help to align regulations to the 2007 law.

Changes include removal of the 4:1 NP-to-physician ratio and the establishment of broader prescriptive authority, increasing NPs' ability to prescribe schedule II drugs from a 72-hour supply to 30 days and schedules III and IV drugs from a 30-day supply to 90 days. Also under the new NP regulations, the board of nursing has proposed that a collaborating physician's name be required on NPs' prescription pads.

During the public comment period, many physicians, NPs and patients submitted their opinions. Medical groups in the state argued that NPs' scope should be defined by collaborative agreements written by physicians. Comments indicated that medical groups oppose the proposed ratio and prescribing regulations. Medical groups also stated that they want a requirement to spell out what "CRNP" means on a name badge, as well as adequate protections to ensure that the patient understands that the health care professional treating them is an NP.

Comments submitted by Pennsylvania Coalition of Nurse Practitioners (PCNP) president Patricia Schwabenbauer, NP, conclude with "In this day and age of a significant shortage of both primary care physicians and nurses, we should all be working together as a health care community to mobilize all the resources we have to improve the health and wellness of our state and country." PCNP agrees with the ratio and prescribing changes, but disagrees that NPs should have to include a collaborating physician's name on their prescription pads.

"The best changes for the public would be for the regulations to become final rulemaking as proposed, with the exception of the requirement to have the collaborating physician's name on our prescription pad," said Susan Schrand, NP, executive director of PCNP. "This issue has confused patients [and] pharmacists and delayed some lab and test results getting back to the ordering clinician. PCNP will oppose this issue; the rest we support."

Schrand also said that more than 450 public comments were submitted, with more continuing to arrive after the Dec. 8 deadline.

A group of leaders from PCNP's executive board met with the House Professional Licensure Committee (HPLC) and the Independent Regulatory Review Commission (IRRC) in November 2008 to discuss PCNP's position on the regulations and educate them about the NP role.

IRRC comments were published in January, and the commission requested information to back up the changes, which could draw out the process. "It was disappointing to read [the IRRC's] comments because it feels like they [are aligned with the interests of] the medical society," said Schrand, who noted that all comments, including those from the HPLC, the IRRC, medical and nursing groups and the public, will be compiled by the BON for consideration. The BON will decide what, if any, changes will be made then submit the regulations for processing.

"There's going to be a lot of work ahead of us, which we anticipated," Scrand said. "And it's such a long process. It's interesting to be in this position because I learn from so many people around the state how little we all know about regulations and the process."

Schrand said that nurse practitioners have already contacted her hoping to hear the good news that they can prescribe schedule II drugs for the new duration. "I have to say, 'No, not for months and months.'"

Schrand was, however, optimistic about what is to come. "I think generally the comments were positive," she said. PCNP has been quite active in recent years, and in 2008 the organization won the state affiliate award from the American College of Nurse Practitioners. "We were very proud of that accomplishment," Schrand said.

Posted March 2, 2009

Kansas
NP Regulation Hearing

The Kansas Board of Nursing (BON) is considering changes to regulations for NPs in the state. Proposed changes reviewed at a hearing in October 2008 include changing NPs' relationship with physicians and other health professionals from collegial to collaborative and allowing NPs to make independent treatment decisions based on the authorization for collaborative practice, among other issues.

Previously proposed regulations were not approved by the attorney general's office in April 2008 because the office recommended removing "diagnosis" and "management" from the language defining NP practice. The regulations were amended to state that NPs will provide nursing diagnoses and will do so as agreed in collaboration with a "responsible physician."

Lou Miller, NP, president of the Kansas Alliance of Advanced Nurse Practitioners, told ADVANCE that "Most of the discussion at the earlier hearing was negative for the changes as there is still 'responsible physician' language in them. Hopefully, with these in place, we can progress on removal of 'responsible physician' language and get nurses removed from other legislation that classifies us as 'midlevel providers' and 'allied health' as well."

The new proposed regulations were approved by the BON and the department of administration in December 2008. Some additional clarifications were requested by the BON. At press time, Sarah Tidwell, legislative chairwoman of the Kansas State Nurses' Association (KSNA), told ADVANCE that the organization was still awaiting word from the attorney general's office about whether the regulations have been approved.

"There were ARNP members on the board [who] stated they would be willing to work with KSNA to identify statutory language that is in line with the National Consensus Model that would resolve the problem," she said. If approved, the regulations would become effective when published in the Kansas Register.

Posted March 2, 2009

National
Retail Clinic Chain Adds Insurer

RETAIL HEALTH NEWS: Health insurance providers are continuing to show their support of the retail health industry and, by extension, nurse practitioners who provide care in convenient care clinics. Tennessee-based retail clinic operator The Little Clinic recently announced that effective Jan. 15, patients with Aetna health insurance will be covered at its locations in Arizona, Colorado, Indiana, Michigan and Tennessee.

Although visits to retail health clinics are affordable, with most episodic illnesses treated for about $60, many more patients with health insurance now pay only a copay. And, in some cases, they pay nothing out of pocket: In 2008, Blue Cross and Blue Shield of Minnesota decided to waive copays for patients visiting retail health clinics in Minnesota. Because Minnesota is the birthplace of the retail health clinic and has a large market - at press time, there were 68 clinics in the state - perks like these are likely to spread to other states as clinic numbers grow, increasing access for patients to affordable health care.

Posted January 29, 2009

National
NP Wins Heart Research Award

Ponrathi Athilingam, NP, assistant professor of clinical nursing at the University of Rochester School of Nursing, recently received the nursing investigator award from the Heart Failure Society of America. She won based on her dissertation research on the use of the Montreal Cognitive Assessment to determine cognitive dysfunction in patients with heart failure.

"My research interest grew out of my many years and experiences," Athilingam said. "As [an NP]working with people who have heart failure, I have seen the overwhelming incidence of frequent readmissions. There are scant data implicating cognitive impairment as a potential factor affecting treatment adherence in heart failure, and cognitive screening is not performed routinely on heart failure patients."

Athilingam told ADVANCE that with this award, she is one step closer to her goal of contributing to research about cognitive impairment in heart failure. "I envision a career pathway that includes identifying biomarkers of inflammation that potentially influence cognition in heart failure as well as early identification and screening for cognitive dysfunction in heart failure."

Ultimately, Athilingam plans to work on development and testing of treatment and behavioral interventions that may help preserve or improve cognitive function among heart failure patients. "This improvement might enhance adherence to a self-care regimen, [increase] quality of life and minimize hospital readmissions and mortality," she said.

Athilingam graduated from nursing school in India in the early 1970s, and she was the first woman in her village to go to nursing school. She went on to earn two master's degrees, one in community health from the University of Liverpool in England, the other as part of an accelerated doctoral program at the University of Rochester. She was the first graduate of this rigorous program, which began in 2002.

Posted January 29, 2009

National
Study Reports High Internet Use by NPs

A survey about Internet use by nurse practitioners, physician assistants and registered nurses showed that most are using the World Wide Web in their practice. Of the 558 respondents to the study by Epocrates, Inc., 92% had Internet access at work, and 84% strongly agree that the Internet plays a much larger role in health care than it did 5 years ago. Most of the respondents reported looking up drug dosing information most frequently online, and 35% looked up information during patient visits. Fifty-five percent said they believed patient satisfaction was higher when they researched information during patient visits.

The survey also showed that NPs use professional sites for clinical information, as opposed to Internet searches. Also, nearly 50% of PAs, NPs and nurses said they have identified a lower-cost or generic medication for a patient through Internet use at least weekly. Furthermore, 80% report saving their patients money within the past month.

Catherine Fontaine, an NP in the New Hampshire Department of Corrections, said the Internet "provides a continually updated source for patient medication handouts for review to enhance the [patient's] understanding of dosing, side effects and length of treatment."

"I would say that at least 75% to 80% of [my NP colleagues] are regular users of the Internet to provide patients with information on illness prevention, importance of treatment adherence and available medications on the specific medication formularies of their insurance plan," Fontaine said. "I utilize the Internet with my patients at least 50% of the time, especially for medication education."

She explained that she uses the Internet to educate inmates about financial burden and generic medications as they prepare for release. "Generics offer an affordable option to increase treatment adherence and thus a more successful re-entry to society."

Fontaine said she accesses the Internet for health- and medication-related information for her patients about six to 10 times a day. "[Because] we do not have electronic medical records, the use of the Web for patient education is extremely helpful, so I can give them something to take back for continued review. The better informed the patient, the higher the medication and treatment adherence."

Posted January 29, 2009

National
NKF Establishes Advanced Practice Council

The National Kidney Foundation has created an advanced practice council to offer a community for nurse practitioners working in nephrology. The Council for Advanced Practitioners serves the needs of nurse practitioners, clinical nurse specialists and physician assistants.

New members receive the foundation publication Primer on Kidney Disease with their membership, along with a quarterly electronic newsletter and the opportunity to participate in an e-mail discussion list to communicate with other council members around the world. In addition, the council awards travel grants for its annual meeting, research grants and awards.

"The council is unique in offering a common ground for advanced practice professionals to enhance their practices and expand their horizons," said Jane S. Davis, NP, communications chairwoman for the council. Learn more by visiting www.kidney.org/about/membership.cfm?jointype=hcp#cap.

Posted January 29, 2009

Florida
Senate Meets to Discuss Report on NPs

In another step toward controlled-substance (CS) prescribing rights for Florida NPs, the Florida Senate met in December to discuss results of a Committee on Health Regulation study of CS prescribing in the state. The report, published in October, cites NP qualifications for CS prescribing and a lack of health care access for Florida citizens as reasons to allow NPs to prescribe controlled substances. (This information was reported in The Front Page section of our January issue.) Specifically, the report states that "ARNPs are skilled nursing professionals with advanced clinical training that prepares them to provide primary care services. Giving ARNPs the authority to prescribe controlled substances will enhance the ability of ARNPs to manage their patients' care and reduce delays and costs for patients in obtaining needed medications."

Approximately 15 NPs attended the committee meeting, and members of the Florida Nurse Practitioner Network and the Florida Nurses Association testified.

"It was clear that there were not enough votes in the committee to support our controlled substances bill as a committee bill," said Julia Pallentino, NP, a member of theFlorida Nurse Practitioner Network. Pallentino said mixed opinions were voiced at the meeting: Some committee members voiced their support and acknowledged that opposition to NP prescribing was an issue of power and money, but others opposed a bill allowing CS prescribing. One senator, who is sponsoring a drug database bill that would track CS prescriptions, asked for more information about the risks of allowing more providers to prescribe controlled substances.

"Ultimately, we concluded that not having a committee bill could be a good thing. A bill filed by a member would only have to come before the committee once, whereas a committee-filed bill would have to make two runs through the committee. Clearly we did not have the votes in the committee to prevail," Pallentino said.

Two strong sponsors for the proposed bill have been identified: Sen. Mike Bennett and Rep. Juan Carlos Zapata. "We also have other allies but have an uphill battle ahead of us," Pallentino said.

Posted January 29, 2009

Florida
New Discount Plan to Include NPs

Blue Cross Blue Shield of Florida has introduced a new option for patients who cannot afford traditional health insurance. The FamilyBlue medical discount card costs $19.95 monthly for a household of six. This new plan does not offer insurance, but offers discounts of up to 60% to individuals and families for drugs and health care services, and it includes care by NPs.

The plan is separate from Florida Gov. Charlie Crist's "Cover Florida" plan, a discount insurance plan that Blue Cross Blue Shield of Florida will also sell for $150 a month. Cover Florida has raised eyebrows in the NP community. Nurse practitioners in Florida face some of the most restrictive practice regulations in the country, so further restrictions to access to care are especially painful to the NP community there.

Although NPs are included as providers in the Blue Cross Blue Shield plan, it seems that the provider list is already outdated, according to Florida Nurse Practitioner Network treasurer Jean Aertker.

"FamilyBlue should be ashamed! The names are mostly all outdated . some are no longer in the practices, and others are not even in practice in the area."

Posted January 26, 2009

National
Leader in Health Care Honored by ACNP

Tine Hansen-Turton, RN, executive director of the Convenient Care Association, chief executive officer of the National Nursing Centers Consortium (NNCC) and vice president of health care access and policy for Public Health Management Corporation, recently received the Sharp Cutting Edge Award from the American College of Nurse Practitioners. The award is given yearly to a person who shows extraordinary commitment to the nurse practitioner community.

Hansen-Turton told ADVANCE that she was honored to receive the award, especially because it is usually given to a nurse practitioner. "I've been excited to see the growth and development of the whole advanced practice nursing movement and the important role that nurse practitioners play in providing accessible, affordable and high-quality care," Hansen-Turton said.

Hansen-Turton became a champion of NPs in the 1990s, when she began working for the Philadelphia Housing Authority. She helped start four nurse-managed clinics where NPs treated patients who lived in public housing. Hansen-Turton remembers the moment she realized the value of the NP role. "The year before we had established a nurse-managed health center, there were 60 births in this particular housing development, and most of the babies were low birth-weight infants because the mothers, who were mostly young, had not received prenatal care, or really any care," she says. A year later, about the same number of babies were born, but none were of low birth weight.

"At that point it didn't take a rocket scientist to realize that this is a provider who really understands how to educate and provide care, and that's when I was sold on what a wonderful resource nurse practitioners are," Hansen-Turton commented.

The program expanded into what is now the NNCC, which advocates for NPs as primary care providers. Hansen-Turton is also active in the retail health industry, which she believes her earlier work opened doors for.

"Because we'd all worked collectively . to get rid of some of the barriers to nurse practitioner practice and we had educated health plans about the importance of including nurse practitioners in their provider networks, it sort of opened the door for me to work in the retail market."

Nurse practitioners have "gone mainstream" because of retail health, Hansen-Turton adds. "Even 5 years ago I had to explain what it is I do, and what a nurse practitioner is; I don't need to explain that to anybody anymore . and that's because nurse practitioners have become a household name."

Posted Jaunary 26, 2009

National
NPs Win Cherokee Comfort Awards

Each year Cherokee Uniforms recognizes health care professionals for service, sacrifice and innovation. This year two NPs were recognized for their excellence in patient care. The winner of the grand prize (a Caribbean cruise for two) in the advanced practice nursing category was Roseanne Warner, a women's health NP who aided a woman in urgent need of diabetes medicine during an overseas flight. She was able to rally passengers for a glucometer and needles and personally paid another passenger for insulin.

Warner also saved her child's teacher's life by noticing his unusual behavior and seeking him out at his home, where she found him incoherent and on the sidewalk. She rushed him to the hospital, where she learned that he had meningitis. Had she not intervened, the teacher would have died. "There is nothing that compares to the human interaction of caring for someone - nothing," Warner said in a press release.

The top national winner in this category (an expenses-paid trip to any conference, membership to a national organization and a $500 donation to a charity of choice) was Normadeane Armstrong, NP, who led an international research symposium on congenital rubella syndrome. Education is her passion. She has instituted a hand-washing program in a local preschool and has conducted pool safety and CPR classes. She also helped form an allergy-friendly soccer league.

Posted on January 26, 2009

National
Two NPs Receive NPHF Fellowships

Mary Beth Bigley, NP, and Catherine Wisner, NP, received health fellowship grants from the Nurse Practitioners Healthcare Foundation. They are completing their second year in the Office of the Surgeon General, providing the best evidence-based science as a reference for public health programs. As the first NP fellows in the surgeon general's office, Bigley and Wisner have provided leadership in critical areas of public health.

"These fellows have demonstrated the importance of bringing the nursing perspective to the forefront of public health discussions," acting surgeon general Steven K. Galson said in a press release.

"Our holistic view of health care - acknowledging the importance of prevention and social issues in addition to clinical interventions - makes us especially effective health care providers," Wisner said in a press release.

Posted on January 27, 2009

Florida
Senate Report Favorable on NPs

The Florida Nurse Practitioner Network (FNPN) has worked with state Senate staffers to create a favorable report on the nurse practitioner role. FNPN hopes this report will encourage legislation to remove the strict barriers to NP practice in Florida, one of two remaining states that do not allow nurse practitioners to prescribe any controlled substances.

The report, presented in October to the state government, concluded that NPs should be granted full prescribing authority: "Senate professional staff recommends that the Legislature consider extending authority to Florida-licensed ARNPs who have attained certification in a nursing specialty from a nationally recognized certifying entity to prescribe controlled substances under protocols and within the scope of practice for their specialty."

"[Senate staffer] Barry Munroe was the author, and we spoke several times. He looked at this from a health policy [perspective] instead of politics and turf wars ... clearly the need is now, and we will use this to move once again on a bill for [controlled substance] authority," said Jean Aertker, NP, treasurer and past president of the FNPN.

A task force was formed in 2008 to study controlled-substance prescribing by NPs. The task force consisted of nine members, including three nurses and other health care providers who work collaboratively with NPs. The task force sought to determine whether NP prescribing of controlled substances would lead to harm. It also aimed to evaluate the possibility of increased prescription drug abuse and did not find any.

Aertker is hopeful that this document, in addition to a white paper written by The Florida Coalition for Advanced Practice Nursing, will "drive the force to get a law passed this year." She emphasizes that Florida NPs must continue to work for more awareness.

"We still need to convince legislators that this is good for Florida, and, no, we will not create a new mass of drug-addicted citizens, as the medical opposition claims still," she said.

Posted December 1, 2008

Florida

NP Accused of Felony in Rx Case
A case of presigned prescriptions has left an NP in Florida facing felony charges for allegedly practicing medicine without a license.

In January 2006, Linda Lindsay, NP, took her first NP job at a clinic providing mostly Medicare and Medicaid services. After several weeks, the physician owner, Sadhana Shah, increased Lindsay's hours.

"She was stressed, she thought she could do it all . and then on Feb. 20, 2006, she gave her notice," said Jean Aertker, NP, president of the Florida Nurse Practitioner Network (FNPN).

Lindsay gave 30 days' notice to Shah. Before that 30 days had elapsed, the physician left the country without notice for 2 weeks. She left presigned prescriptions, which Lindsay used to refill current patients' medications while Shah was away. Because Florida NPs do not have independent prescriptive authority, presigned prescriptions are commonly used, but illegal.

Eventually Lindsay inquired as to how her prescriptions were being billed, because she had not yet obtained a Medicare number. The day Lindsay left the practice (March 20, 2006), Shah and the office manager called the sheriff's department and claimed that Lindsay forged the physician's signature while Shah was away. An investigation ensued, and in May 2007, Lindsay was arrested. She was released on $5,000 bond to await trial.

After depositions this year by two supporting physicians, Scott Plantz and Dan Mountcastle, Shah revealed under oath that she presigned the prescriptions. But the charges against Lindsay were not reduced. The case has built slowly since then, and Lindsay has been unable to practice .

When presigning of prescriptions occurs, physician and NPs are not treated similarly. If a physician in Florida presigns a prescription, penalties are generally light. Because it is a violation of the practice act, they typically are fined a few thousand dollars, are required to obtain additional CME credits, and their license may be suspended.

An example of this is a 2006 case (Department of Health v. Ernest G. Haslam) in which Haslam received a "reprimand" from the Board of Medicine and was ordered to pay a $5,000 fine, reimburse costs, take a drug course and perform community service.

The treatment of nurse practitioners in Florida is quite different. If an NP issues a presigned script, the potential penalty is a charge of practicing medicine without a license, which is considered a third-degree felony and can result in up to 21 months in prison and permanent revocation of a license. Many NPs in Florida are unaware of the severity of these penalties. In this case, the sheriff's office decided not to press charges against Shah for presigning the prescriptions. "That's why we [NPs] need to be on our own paper, none of this protocol stuff," Aertker commented.

"This is the grossest miscarriage of justice I can imagine," said Plantz, one of the physicians who has publicly sided with Lindsay. "This is a violation of the nursing practice act, not practicing medicine without a license; that's reserved for the janitor who pretends to be a doctor - that's criminal. What Linda did was make the mistake of an uninformed person . she needs education and a slap on the wrist. Period. Nothing more."

A jury trial in the case was scheduled to start Nov. 12, and the FNPN offered Lindsay help in finding expert witnesses and legal advice. A trial was averted at press time, however, when Lindsay accepted pretrial intervention. This procedure offers an alternative to formal prosecution and will expunge her record after an as-yet-undetermined period. Lindsay plans to practice again at that time.

Joe Bodiford, Lindsay's first attorney, declined to speak with ADVANCE. Cynthia Hernandez, Lindsay's current attorney, did not respond to requests for a statement, nor did Justin Peterson, the prosecutor for the state.

According to Aertker and Plantz, many physicians and NPs have offered to testify that they, too, have used presigned prescriptions, that many of them were unaware that it was illegal, and that the practice does not warrant a felony conviction.

"These laws are corrupt and should not be allowed to destroy a life," Plantz said. "You do not put people in jail for not being educated."

Posted December 1, 2008

National

Study on APN Effectiveness Announced
For the first time in 20 years, a study has examined the effectiveness of advanced practice nursing on patient outcomes and health care quality. Twenty-seven nursing organizations have come together as the Tri-Council for Nursing to commission this long-awaited research.

"A sweeping review of the scientific literature on the quality, safety and effectiveness of care provided by APNs is needed to inform educational, policy and organizational decisions," said Robin Newhouse, principal investigator for the study, in a press release.

The study's report, which will be titled "An Assessment of the Safety, Quality, and Effectiveness of Care Provided by Advanced Practice Nurses," is planned for publication in January 2009.

Posted December 1, 2008

National

Longtime AANP Executive Director Retires
Judith Dempster, NP, recently announced her retirement from the American Academy of Nurse Practitioners (AANP) following 12 years of service as the first executive director of the professional organization. Dempster will continue in her role as executive director of the AANP Foundation through 2009.

"My years at AANP have been challenging and rewarding," Dempster said in a statement. "It has been a true pleasure to help the organization grow and flourish. ... Much has been accomplished - including creating a foundation and a national certification program (both independently incorporated); constantly expanding our advocacy role; becoming a proactive force in shaping health policy; developing a PAC; creating a national NP practice-based research network; expanding our international activities and presence; dramatically increasing membership benefits; maintaining the only national database of all NPs; initiating the only fellows program (FAANP) to recognize NP excellence; and hosting the largest national conference for NPs."

AANP president Dee Swanson, NP, also commented: "Today, as a result of [Dempster's] leadership, AANP is truly representing the interests of all nurse practitioners."

Posted December 1, 2008

Montana

Restraint-of-Trade Case Continues
The nurse practitioner-owned clinic in Butte, Mont., that encountered restraint of trade when a neighboring hospital refused to accept radiology orders from the NP owners has closed. Meanwhile, their legal case is inching along in the court system.

The problems began when Vicki Thuesen, NP, and Shari Healy, NP, received notice from the physician director of radiology and pathology at St. James Hospital that he would no longer accept their referrals for imaging "other than routine x-rays" without physician supervision. The radiologist filed complaints with the Board of Medical Examiners charging that the NPs were "practicing medicine." These were dismissed. Various factors resulting from the restraint of trade forced the NPs to close the clinic earlier this year. Thuesen and Healy have filed a lawsuit against the radiologist and the hospital.

"The lawsuit was supposed to go to trial in October," Thuesen told ADVANCE, "but the defendants felt that they weren't ready and so they asked for an extension. [Now] it's scheduled to begin in June 2009." The trial is expected to last a month, so it had to be worked into the judge's schedule when enough time was available.

Thuesen said the trial may be shorter than 4 weeks because some of the defendants have settled, but none of those who did are directly involved in the restraint of trade. She and Healy agreed to the extension to avoid appeals after the trial. "We're still doing depositions and just going about getting ready," Thuesen said.

Thuesen and Healy's expert witness is a forensic accountant who has calculated damages. "[This] was a good thing to finally see on paper . to project when Shari and I would have planned on retiring, what we would have lost based on them closing the clinic," Thuesen said.

Thuesen now lives and works in Dylan, Mont., 45 miles from Butte. "The interesting thing is . I'm working independently without physician supervision, and St. James Hospital is accepting my orders. I don't know if they realize they are, because they're not supposed to be, so that's going to be an interesting twist . how are they now allowing me when I'm still independent?"

Healy is now teaching and works several days a week for a pediatrician in Butte. The hospital is not accepting her orders without a physician's cosignature. "But they're accepting mine without physician supervision or cosignature, which they wouldn't when I was working across the street and competing directly," Thuesen said.

Posted December 1, 2008

National

Studies Document Retail Health Benefits
RETAIL HEALTH NEWS: Two recent studies of retail health visits found that convenient care is providing needed access to health care at an affordable price. A study by RAND researchers (Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits. Health Affairs. 2008;27[5]:1272-1282) reviewed a combined 1.35 million visit records from eight retail health chains and found that most visitors to retail clinics (61.3%) did not have a primary care provider. So, NPs at these clinics are providing care to patients who otherwise may not have sought it.

The study also showed that most visits (90.3%) to retail clinics were for 10 common health conditions, the top five of which are upper respiratory symptoms, pharyngitis, immunizations, otitis media or externa, and conjunctivitis.

A second study, conducted by HealthPartners (an insurance plan and health care system), examined only visits to MinuteClinic locations. It found that for common conditions, the cost of care in a retail clinic is up to 35% less than that in physician offices and urgent care locations. And, it is 73% less than care received in emergency departments. Both studies showed fast growth in clinic use, and more use by women and generally healthy people.

"Nurse practitioners are very well trained and if anything the reason I think [retail health care] could even possibly be better is nurse practitioners generally have a lot more time," said Ateev Mehrotra, one of the RAND study authors, in a webcast on Medpagetoday.com.

"This will not quell the rancor, but at least people will have some facts to talk about," Mehrotra told Reuters.

Posted December 1, 2008

"As the organization of choice for all advanced practice nurses working with older adults, we are excited that our new name emphasizes our expanded focus to reach out to APNs with other certifications who also provide care to older adults," GAPNA said in a statement.

NEW YORK
Collaborative Practice Bill Progresses
A bill known as the Patient Access and Advocacy Act has been introduced in both houses of the New York State Legislature.

The bill calls for fair reimbursement to nurse practitioners from third-party payers and, more importantly, the legislation would eliminate mandatory collaborative agreements for nurse practitioners to practice, making New York an independent practice state.

The bill was drafted by the New York Nurse Practitioner Association (NPA) and is sponsored by Sen. Catharine Young and long-time NPA supporter Assemblyman Richard Gottfried. NPA's lobbyists have been continuously working to engage legislators regarding this bill. Grassroots action has included a letter-writing and phone call campaign to district offices and has resulted in the addition of several cosponsors.

Denis Tarrant, NP, public relations task force chairman for the NPA, said that when nurse practitioners in New York were defining their practice in the 1980s, "The way we were going to get our independence was if we agreed with the AMA to collaborate with a physician." New York requires physician chart review throughout the year.

Tarrant called the collaborative agreement a "paper tiger" that hasn't improved patient outcomes. He noted that 13 states don't require collaborative agreements with physicians.

"A nurse practitioner can set up shop and establish a practice and see patients independently. And those states have been doing very well," he pointed out. "So in New York, the NPA thought it was about time that we become the 14^thstate to practice without these collaborative agreements."

Third-party payers operating in New York sometimes don't reimburse NPs at all, or they only reimburse 40% to 50% of the physician's rate, Tarrant explained. This dissuades many NPs from becoming part of provider panels.

Tarrant wonders about the reason for the agreement. "Instead of asking what's wrong with [the law], we're asking what's right with it." He explained that in order to grow his private practice and hire more NPs, he needs a collaborating physician. "And if my collaborator decides he doesn't want to do it anymore, or he wants to move to another state, then 250 patients have no care."

Tarrant considers it imperative that this change be made because of the physician shortage and the aging of the population. He added that patients also want more choice, "and the only way to make more choice is to have an open and competing market. That's what we bring to the table: Competition brings better care, people stay out of hospitals, and [this] keeps the costs down."

These changes won't come easy, Tarrant acknowledged. "Historically, the AMA has lobbied against every bill we've put forth to the governor. It's going to be a tough battle, but I think reason will come out on top here. These agreements don't show greater patient outcomes."

NATIONAL
Congress Overrides President's Veto
Congress overrode President Bush's veto of a bill to delay reimbursement cuts to physicians and, by extension, to nurse practitioners. The final vote easily upheld the two-thirds requirement for override of a veto.

The bill, called the Medicare Improvement for Patients and Providers Act of 2008, amended titles XVIII and XIX of the Social Security Act to delay a 10.6% pay cut to physicians seeking reimbursement for treating Medicare patients. Under the legislation, the current payment rate will be valid through 2008 and increase by 1.1% for 2009. It also delays cuts to pharmacy reimbursements and aims to improve access to health care and enhance low-income benefit programs for the more than 44 million Medicare recipients.

"This is good news that we did not have to deal with the cuts in Medicare, for both our patients and us as providers," said Susan Schrand, NP, president of the Pennsylvania Coalition of Nurse Practitioners.

When Congress originally voted on the bill, an ailing Sen. Edward Kennedy, D-Mass., returned in a show of support to complete the voting in the Senate. Bush vetoed the bill in July, stating that he disagreed with the planned financing to delay the pay cut, which would include reducing payment to private health plans serving more than 9 million older and disabled Americans. "Taking choices away from seniors to pay physicians is wrong," the president said in a statement.

The Centers for Medicare and Medicaid Services (CMS) implemented a retroactive payment to cover claims by health care providers made during the time when the 10.6% reimbursement cut was active. A fact sheet about this reimbursement is available at www.cms.hhs.gov/apps/media/fact_sheets.asp.

ARIZONA
Scope-of-Practice Bill Stirs Emotions
A bill that would have made it illegal for nurse practitioners to perform abortions failed in the Arizona Senate, but associated events signal the potential for spirited debate about NP scope of practice in 2009.

The bill was amended in a process that replaced language with wording to address a completely different issue (a "strike everything" amendment). It changed from a statute to regulate copying fees to one that would have changed the nurse practice act.

At the same time the bill was being considered in the Legislature, the Arizona Board of Nursing (BON) was deliberating whether abortion was in the scope of practice of nurse practitioner practice under the existing nurse practice act. The board also discussed the case of a nurse practitioner who had been performing first- and early second-trimester aspiration abortions for 7 years.

The amended bill was introduced in March by Rep. Bob Stump. On the House floor, Stump expressed the opinion that all surgical procedures should be performed by physicians and that to permit otherwise would put the health and safety of the public at risk, said Angela Golden, NP, vice president of the Arizona Nurse Practitioner Council, part of the Arizona Nurses Association.

Nurse practitioners and voters wrote letters to legislators expressing their concerns about the definition of "surgical procedure" and where this could possibly lead in relation to other, similar procedures that NPs perform. Women's health experts also expressed concern about whether aspiration abortion is a surgical procedure and, if such a bill were passed, what bearing it would have on other procedures involving similar skills and judgment (e.g., intrauterine device insertion, endometrial biopsy, incision and drainage, colposcopy and loop electrosurgical excision procedures).

The NP council was concerned by Stump's argument that only physicians could safely perform medical procedures. The council also worried that this action could set a precedent of introducing legislation that affects nursing practice without input from the regulatory and professional nursing community. When the bill was amended, the BON had not commented on the issue, Golden said.

In May, the BON issued an advisory opinion that first-trimester abortion was within the scope of practice of nurse practitioners who demonstrate the necessary education and skills. The bill passed the House before the BON issued its opinion. In the Senate vote that occurred after the May BON meeting, senators defeated the legislation.

At the BON and in the Legislature, the NP community expressed concern about the ramifications of changing the broadly worded nurse practice act to regulate a specific procedure. Nurse practitioners also spoke out against the legislation because it claimed that all health care procedures carrying risk should be provided by physicians.

"There are many procedures that nurse practitioners, and nurses for that matter, perform that carry a much higher risk than aspiration abortion," said Denise Link, president of the Arizona Nurse Practitioner Council. "If such a precedent is set with this procedure, what is next?"

The issue became emotionally charged as well. "There were a few nurse practitioners who reacted negatively to opposition to the bill, because they believed that opposition to the bill meant that nurses were supporting abortion," Link said. Others expressed their opinion that abortion is not within the scope of practice of NPs because it is a surgical procedure, but Link said these two groups were in the minority in the discussion.

"For the NP leaders in Arizona, it wasn't about abortion," said Karen Holder, coordinator for the Northern Arizona Nurse Practitioner Group.

It remains to be seen what the actual effect of the bill's defeat will be. "I do not foresee significant numbers of nurse practitioners seeking education and clinical training in aspiration abortion, since a number of the nurses who spoke out against the legislation also mentioned that they personally would not be interested in providing that service," Golden said.

"It was a very successful campaign for scope of practice and maintaining it," Holder pointed out.

Arizona will be opening its nurse practice act in the 2009 legislative session for some cleanup. "That is why it was so important to clarify the issues in HB 2269 that related to determination of scope of practice," Link said.

"However, if the proponents of the bill are determined to make the change, we may be revisiting this issue in the coming legislative session, because the opening of the nurse practice act provides a golden opportunity. If that happens, we are going to have an emotional redux."

MISSISSIPPI
Survey: Conditional Physician Support of NPs
Mississippi physicians who responded to a recent survey about nurse practitioners voiced mixed attitudes about the profession - even though two-thirds of them already employ or work with NPs.

A recently published policy brief details the survey, which was sponsored by the Mississippi State Medical Association, the Mississippi Academy of Family Physicians, the American Academy of Family Physicians and the Social Science Research Center at Mississippi State University. It asked 848 physicians in Mississippi about their acceptance of the growing number of NPs as primary care providers in the state.

According to the survey, equal numbers of respondents claimed there were too few and too many NPs in the state. Almost 80% of respondents said they agree that NPs can offer quality care when supervised by a physician, and fewer than 1 in 6 said they favored independent NP practice. More than half said they believed NPs provide lower quality care than physicians.

"The [results are] really not surprising," said Jackie Williams, NP, director of advanced practice for the Mississippi Nurses Association (MNA). For the most part, NPs in Mississippi report collegial professional relationships with their collaborating physicians, she explained. "But the physician still likes to be the head of the medical model."

In an article posted on Redorbit.com, Mississippi family physician Tim Alford commented: "My perception is that the state is in dire need - not just rural areas - and these professionals add to the health care work force, provided they have supervision. ... But I do have reservations with them being out on the front line."

A task force appointed by Mississippi's board of medicine (BOM) and board of nursing (BON) meets periodically to discuss issues relevant to health care issues. "We have in the last year seen a definite move toward increased control of NP practice," Williams said. The task force has pressured the BON on issues of quality assurance plans, mileage between practices and the number of NPs a physician may collaborate with.

"Thus far, the BON has only agreed to a loose (but still) 10% review of charts. [But] this is proposed at this point and not yet jointly promulgated," Williams said. "I see this as a big move backwards, but thus far the MNA has been unable to veer the BON from this 'compromise.'"

Williams said that although the public's understanding of the NP has matured considerably, she believes many Mississippi physicians are still not knowledgeable about the nurse practitioner role. Williams is encouraged by the fact that the BOM asked the BON to include a booth about NPs and NP practice at its annual meeting. "That's progress," she said.

"According to our NP database at the BON, 50% of physicians collaborate in some form with an NP again, that's progress," Williams said.

A bill introduced in the U.S. House of Representatives would include nurse practitioners in the language of a Medicare law to allow NPs to order home health and hospice care. Currently, NPs are able to be the attending care provider for a home health or hospice patient, but they cannot certify a patient for that care.

In 2007, Pennsylvania Gov. Edward Rendell signed a law stating that NPs have the education and ability to order home health and hospice care. But the law did not supersede the authority of the U.S. Department of Health, which recognizes only physician orders for home health or hospice care.

"Even though Rendell said this is really integral to the health of our state, and [nurse practitioners] know how to do this, we're still prohibited to do it ? so we really needed to work at the federal level," said Susan Schrand, NP, executive director of the Pennsylvania Coalition of Nurse Practitioners (PACNP).

The PACNP worked to help introduce language to include NPs in home health decisions in the Senate. But PACNP still needed support in the House.

"We were targeting Rep. Allyson Schwartz, who is on the Ways and Means Committee, which deals with Medicare issues," Schrand said. In August, Schwartz introduced the Home Health Care Planning Improvement Act, HR 6826.

"So far, 39 cosponsors have signed on, which is great," Schrand said. She has been leading the campaign to garner more cosponsors. "We need to keep encouraging the federal legislators in the House of Representatives to support this bill, [since] it will enable us to order home care for our patients."

Schrand said NP organizations have expressed support, but it's wise to be cautiously optimistic. "Whether it will take wing and soar I don't know, but it's good that it was at least introduced."

RETAIL HEALTH NEWS: Take Care Health Systems, which operates Take Care clinics in Walgreens stores, has decided not to renew its commitment to the "Desired Attributes for a Retail Health Clinic," a set of guidelines developed by the American Academy of Family Physicians (AAFP).

"The main reason we did not re-sign those attributes was because of [the document's] statement for a limited scope of services for the retail clinics," said Sandra Ryan, chief nurse practitioner officer for Take Care. She explained that although Take Care was involved in the creation of the attributes and that the company still maintains communication with the AAFP, Take Care is seeking to offer additional services in the future and therefore could not adhere to the guidelines.

"We still have a well-defined scope and high-quality care," Ryan said. Take Care still follows the other guidelines, which include using evidence-based medicine, collaborating with physicians, referring patients appropriately and using an electronic medical record.

"Some of the other clinics are providing disease management because there is a need," Ryan explained. Retail clinics are offering services such as diabetes management, asthma management and weight management.

"We are much more national in scope and able to take our services to the marketplace based on what [patients] are demanding," said Lauren Tierney, spokeswoman for Take Care. Tierney said that when Take Care started offering the shingles vaccine, more than 3,000 shots were administered in about 45 days.

"There just aren't enough access points for things that we are actually recommending as a health care industry," Ryan said, mentioning the shingles and HPV vaccines as examples. "We can be a first responder to things that need to be initiated in the United States as far as immunization practices and best practices in helping to reduce chronic diseases." Because customers want to be proactive in their health care, she said, "This will improve access as well as quality of life."

Insurance companies are even making it easier for patients to access retail health care, according to a report in the Minneapolis-St. Paul Business Journal. The article stated that Blue Cross Blue Shield (BCBS) of Minnesota will eliminate copays for members who use retail clinics. According to the report, the insurance company wants to encourage visits to retail health clinics, which numbered more than 40,000 in Minnesota in 2007.

"We created this new option because it helps hold heath care costs down and is responsive to consumers' wide acceptance of retail clinics," said Shawn Patterson, vice president of marketing for BCBS, in a statement. According to news reports, the company estimates that employers and members insured by BCBS saved more than $1.2 million in health care costs in 2007 by using retail clinics.

Deborah Koniak-Griffin, NP, received the Award of Excellence in Research from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) at its annual conference. Koniak-Griffin, a women's health nurse practitioner, is a professor at the University of California-Los Angeles School of Nursing. She is also director of the school's Center for Vulnerable Populations Research, which she established 9 years ago. Koniak-Griffin has made significant contributions in the area of adolescent parenthood, with a focus on ethnic and racial minorities.

Koniak-Griffin has more than 20 years of clinical NP experience in hospital-based obstetric and newborn nursing and now practices part time at the Venice Family Clinic in Venice, Calif.

The research excellence award is presented to an AWHONN member who demonstrates a history of conducting federally funded research, who has published research in refereed journals, and who reflects AWHONN's goals and standards in their contributions to nursing research focused on the care of women and newborns.

Koniak-Griffin has conducted research funded through the National Institute of Nursing Research (NINR) and has authored more than 150 publications.

"I am thrilled to be the recipient of this very distinguished award from AWHONN. It is truly an honor that I will always cherish," Koniak-Griffin said. "I am particularly pleased that my research is building evidence-based practice for the nursing care and health promotion of adolescent parents and their children."

The Nurse Practitioner Healthcare Foundation (NPHF) recently awarded $1,000 scholarships to nurse practitioners for their exceptional work in community service, gastroenterology and the promotion of diversity in health care. The scholarships are aimed at encouraging NPs to take a proactive approach to improving health care in their communities and at promoting diversity within the NP profession.

Winners of the NPHF/Procter & Gamble 2007-2008 Community Service and Gastroenterology Endowed Scholarship include Diane Nunez, NP, who coordinates a program in Tempe, Ariz. that emphasizes the functional health, physical fitness and quality of life of older adults. Also winning this scholarship was Jennifer Hill, NP, who plans to open a clinic for children with obesity-related gastrointestinal issues. Through this clinic, overweight children will learn how weight affects health, and each child will meet with gastroenterologists, dietitians, counselors, personal trainers and other experts.

Winners of the NPHF/AstraZeneca 2007-2008 Diversity Scholarships include Ukamaka Oruche, NP, of Indiana, who focuses on child and adolescent mental health. She works with children in outpatient mental health clinics, schools and juvenile detention centers. With such a diverse group of patients, she must use culturally sensitive treatment approaches. She invites staff and patients to attend monthly cultural competency meetings. Jimmy Reyes, NP, plans to open a free clinic in Iowa to bring quality health care to migrant farm workers, minority groups, older adults and Spanish-speaking populations. Brenda Trogdon, NP, opened a free clinic in rural Florida to treat black, Hispanic and Native American populations with limited health literacy. She operates this free clinic in her home. At the same time, she runs a military base medical facility for teens at risk. In the future, Trogdon plans to open a free clinic in her hometown of Starke, Fla.

For the first time, all health insurers operating in Massachusetts will be required to recognize NPs as primary care providers. They must also list them in provider directories with physicians, so that patients may choose them to coordinate and direct their care.

SB2526 was proposed as an update to a Massachusetts health care law and was designed to reduce health care costs. The bill called for creating a statewide electronic medical records database that would allow patients to choose nurse practitioners as primary care providers.

The bill also sought to prohibit pharmaceutical company sales representatives from offering gifts to prescribers.

Senate President Therese Murray championed the bill, asserting that in order to keep making progress on the state's landmark health care reform efforts, this bill should become law.

"We must contain costs and increase access to primary care if we expect to keep our health care system viable and sustainable," she told the Boston Globe.

"[Each] NP's outcomes will be linked with his or her work and not hidden within the collaborating physician's," said Bethann Rowlands, legislative chairwoman of the Massachusetts Coalition of Nurse Practitioners (MCNP) and chairwoman of the organization's political action committee.

"This will be vital to have once pay for performance is implemented. We will want to be able to see our outcomes and have them measured so we can be reimbursed," Rowlands added.

Massachusetts joins 24 other states that recognize NPs as primary care providers. Language addressing the definition of a primary care provider was first proposed as S1226 by the MCNP last year. The bill made it out of committee and into the Senate, but it was not voted on before the end of the session. This year the language was added to S2526. The bill faced little opposition in the Senate, and all language remained intact until it was reviewed by the House of Representatives. There, key language was changed that altered the intent of the bill. Through grassroots efforts and focused lobbying by MCNP, an amendment was drafted and accepted, and the House voted and approved the bill - all within a matter of hours.

"It was a late night, very tense. It was through our strong relationship with the Senate president that our language was retained at those very last moments and the governor signed it into law," Rowlands said. The bill was signed into law by Gov. Deval Patrick on July 31.

Rowlands attributes much of the success to the grassroots efforts of the MCNP. "The NPs in Massachusetts were very supportive of our legislative efforts and responded to all of our 'call to action' and lobbying efforts," she told ADVANCE. She said that many NPs even hosted private fundraiser events in their homes to help garner the support of key legislators.

"The most important thing we did was to gain the support of the Senate president," she said. "The health plans were against us the entire way. [Whenever anything] hit the media, we made sure we responded to it with a statement from our president and then rallied our members to make calls and write letters."

Rowlands also noted that the MCNP had particular success in communicating with NPs through their e-mail list, which 65% of the MCNP membership subscribes to.

"We sent regular updates with clear instructions for next steps to support the bill. If any NP got a response from [a] legislator, [she] sent it to us and we shared it with our lobbyist. All were followed up on by our lobbyists," Rowlands said.

A Yale University nurse researcher is seeking RNs with hearing, vision or communication disabilities to participate in a study designed to measure work instability.

Participants will complete several questionnaires that take less than 15 minutes to finish, and no identifying information will be disclosed.

For more information, e-mail Leslie Neal-Boylan, PhD, RN, at leslie.neal-boylan@yale.edu or call 203-785-3337. The study ends December 31, 2008.

Nursing groups have created the first general consensus document about advanced practice nursing. NPs in almost all states are regulated by state boards of nursing. Multistate licensing can be a challenge when the NP role is defined or regulated differently in multiple states where an NP wants to practice. At least one multistate partnership, between Utah and Iowa, has been developed, but a broader collaboration would be helpful to NPs moving to other states and those interested in the growing trend of telemedicine.

At its June meeting in Washington, D.C., the American Nurses Association's (ANA) board of directors endorsed a document that it believes will be beneficial to all NPs across the country. The document, "A Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education," proposes a standardized model for advanced practice nursing certification and education. Developed by a joint dialogue group consisting of the APRN Consensus Work Group (created by the American Association of Colleges of Nursing) and the APRN Committee of the National Council of State Boards of Nursing (NCSBN), the standard model will allow NPs to be licensed in multiple states more easily. It also will establish independent practice as the norm rather than the exception.

The consensus model defines four "roles" for advanced practice nursing: certified nurse practitioner, certified registered nurse anesthetist, certified nurse midwife and clinical nurse specialist. It then narrows these down into six "population foci": psych/mental health, women's health, adult-gerontology, pediatrics, neonatal and family. NPs can choose at least one population focus and then study and gain certification in specialties. NPs licensed by boards of nursing under this model will be licensed to practice independently, with no supervision or collaboration. Enforcement of this license "will have to come about as a result of changing the statutes in each state nurse practice act or state practice act," said Mary Jo Schumann, NP, director of nursing practice and policy for the ANA.

The consensus document also addresses certification and education by creating "LACE," a collaboration between licensing bodies, accreditors, certifiers and educational bodies that set standards for education. All graduate-level NP education programs will be required to first focus on one of the four roles and then on the patient population. Programs will also include courses in advanced pathophysiology, advanced health assessment and advanced pharmacology - plus at least 500 clinical hours. All programs will go through a preapproval, preaccreditation or accreditation process before admitting students. Programs must be part of nationally accredited graduate programs, and they must ensure that graduates would be eligible for national certification and therefore state licensure.

"This will support [NPs] caring for patients in a safe environment to the full potential of their nursing knowledge and skill," ANA president Rebecca M. Patton said in a press release.

"We are in the process of having the national nursing organizations and stakeholders review the document and endorse it," Schumann explained. The final draft of the document will be presented at an NCSBN House of Delegates meeting for endorsement. Endorsement from many organizations is important to creating unified support when the model is put forth for acceptance into state statutes. "The AMA is aggressive in fighting other health care professions, and this is going to get their attention," Schumann noted.

NATIONAL HARBOR, Md. - More than 3,400 nurse practitioners from across the country gathered in this Washington, D.C., suburb to attend the 23rd annual conference of the American Academy of Nurse Practitioners (AANP) in late June.

Nurse practitioners traveled to Capitol Hill to meet their representatives in Congress and reported that they valued the experience. "I wish I had lobbied my representatives and senators sooner. Thursday's lobbying experience made me realize that we can make a difference by explaining to our [elected officials] who we are and what we do," Dianne Okonsky, NP, told the AANP Conference Call on-site newspaper.

NPs also took part in hundreds of conference sessions and poster presentations. Presentations addressed practical as well as clinical information in specialty areas such as research, acute care, women's and men's health, pediatrics, gerontology, integrative medicine, occupational health, pharmacology and mental health. Other sessions focused on business and professional issues such as practice ownership and certification. Hands-on workshops were also popular; NPs donned their gloves for basic suturing and toted yoga mats to a workshop on yoga, tai chi and qigong. The exhibit hall was packed with the latest products and services for NPs and NP students.

Hot topics at the conference included the doctorate of nursing practice (DNP) degree and retail health. Members of the ADVANCE for Nurse Practitioners editorial team attended sessions on both of these much-discussed issues. Jan Towers, NP, director of health policy for the AANP, told a packed session on NP regulation that the DNP is "where we should have been all along," because the master's degree for NPs is already overloaded with material in comparison with other master's degrees. "The quality of our master's programs is such that we don't have to move much," she commented.

In a session about how NPs and PAs work together, Mary Jo Goolsby, NP, director of research and education for the AANP, and Greg Thomas, vice president of professional education and alliance development for the American Academy of Physician Assistants (AAPA), presented their thoughts. Both presenters touted the collegial relationship between AANP and AAPA, but they stressed that NPs and PAs cannot speak with one voice because they practice two distinct models of care. "We work very well together, and although organizations may use ?competitor' language, that's not the case," Goolsby added.

At the AANP membership meeting, thousands of NPs gathered to honor state award winners and to welcome Diana "Dee" Swanson, NP, as the new president of AANP. Outgoing president Mona M. Counts, NP, passed the gavel on to her and wished her well.

RETAIL HEALTH NEWS: The Little Clinic announced that the Kroger grocery chain has made an investment that will lead to a "substantial clinic rollout." The Little Clinic now operates in 26 Kroger stores. According to a news release, new clinic locations are planned nationwide. "We share a commitment to deliver innovative, quality, affordable health care to consumers across the country," said Molly F. Ashby, founder and CEO of Solera Capital and chairwoman of The Little Clinic.

John Grzybowski, president and CEO of The Little Clinic, emphasized the quality of care provided by nurse practitioners. "Kroger customers who visit our clinics are impressed by the attentiveness and expertise of our medical professionals."

By creating a partnership with a large retail corporation, The Little Clinic joins other large retail health chains that have done so. These include MinuteClinic, RediClinic and Take Care Health.

West Virginia nursing groups are working to improve health care access to the state's residents and to remove practice barriers to nurse practitioners. But the state board of medicine has aggressively opposed these changes and is working to further restrict NPs. As a result, hundreds of NPs have left West Virginia to work in other, less restrictive states. According to a 2007 report by the West Virginia Nurses Association (WVNA), approximately 300 NPs, more than 20%, have left the state since 2006.

Two particular issues are causing NPs to leave West Virginia. First, prescriptive authority in the state is restrictive. The West Virginia Board of Examiners for Registered Professional Nurses has worked with stakeholders to create a new rule that would ease restrictions on the amounts, refills, types and routes of administration for prescription medications. But the legislative arm of the West Virginia Board of Medicine (BOM) has opposed all changes, claiming inadequate education of nurse practitioners and an increased risk for patient addiction to narcotics.

The BOM also proposed a surgical rule that would further restrict NP practice. The rule defines the practice of surgery, and its language would prevent NPs from performing any skin procedure - including suturing, administering injections and removing skin lesions. The proposed rule defines surgery as anything that structurally alters the human body, including procedures using lasers, scalpels, probes and needles. It would require that a physician be present if an NP provides any of these services.

"It is my opinion that this rule has the potential to eliminate the [nurse practitioner] role entirely," said Alvita Nathaniel, NP, director of the family nurse practitioner track and assistant professor at West Virginia University. She made the comment in a letter she sent to nursing groups. "If we want to continue to practice in our current roles, we must actively oppose this rule change."

The comment period for the surgery rule ended in July, after which the BOM decided to revise the rule to exclude nurse practitioners with collaborative agreements from the restriction. At press time, WVNA planned to pursue a second public hearing for the rule. If the BOM decides to pursue it as a rule, it will request that the Legislature approve it (through each house's rules committee) in 2009.

An additional potential barrier to NP practice looms in the distance: Last year, the state's BOM proposed a bill that would make it a felony for any person who is not a physician to "practice medicine" using the title "doctor." Although the bill failed, it is likely to appear again. If enacted, the bill would bar nurse practitioners with DNP degrees to use the title "doctor" professionally.

NPs in the state continue to work toward removing practice barriers and providing necessary health care to the residents of West Virginia. "WVNA APN Congress is working very hard on public recognition of this proposal," said Beth Baldwin, NP, chairwoman of the group. "We are also copying these letters to our legislative representatives."

Grassroots efforts to stop these proposed changes include an e-mail questionnaire sent to all providers who could be affected by them. ?It asked several questions to gather information that would be useful to show legislators how the health care of West Virginia residents would be adversely affected by the changes.

A rules and regulations change that could be completed soon in Vermont would provide independent practice status to NPs and increase patients' access to primary care.

In the state's 2007 legislative session, the Vermont Nurse Practitioners Association (VNPA) provided testimony to the House and Senate health committees for the purpose of educating and advocating for NPs. Based on the testimony, the Legislature passed Act 71, which will help ensure health care reform. One section of the act called for a study of whether the collaborative practice requirement for NP practice should continue. The law noted that NPs "might serve a greater role as primary care providers who provide essential chronic care management."

A multidisciplinary task force made several recommendations to the Vermont Board of Nursing (BON) after the act was passed. These included recommendations to eliminate the requirement for NPs to have a written signed collaborative agreement with a physician, to require an NP appointee to the BON and to create a mentor-mentee program for new graduate NPs.

Jennifer Laurent, NP, president of the VNPA, told ADVANCE that the House Health Committee endorsed the recommendations. "The House Health Committee sent a letter to the BON asking them to expeditiously move forward with removing the [requirement for a] practice agreement," she said. A majority of the task force agreed that the collaborative practice requirement should be ended.

After these recommendations were made, Laurent met with Mary Botter, executive director of the Vermont BON, to discuss removing the collaborative practice requirement. Botter requested that an NP advisory group be formed to make recommendations to the BON as to how the change would occur. The BON would then accept or reject the advisory board's recommendations, then present final recommendations to a professional operations committee.

In addition to seeking comments on collaborative practice, the advisory board will continue to meet to provide guidance on NP issues in Vermont and to make comments on all changes recommended by the task force, including practice by new graduate nurse practitioners. The advisory board will address whether new graduates will be able to automatically practice or must first complete an internship.

"Because the climate is really hot right now, and the primary care shortage is all over the papers and all over Congress, [Botter] and VNPA agree that we need to move. People have had enough of not being able to get care," Laurent said.

August 2008

The National Association of Pediatric Nurse Practitioners (NAPNAP) gave more than 40 awards, scholarships and grants at its recent annual conference. Most notable was the Loretta C. Ford Distinguished Fellow Award, which was given to Bernadette Melnyk, NP, dean of nursing at Arizona State University and a member of the ADVANCE for Nurse Practitioners editorial advisory board. The award, named for the cofounder of the NP profession, is given annually to a NAPNAP member who best exemplifies contributions to the expansion or improvement of pediatric health care and the advancement of pediatric nurse practitioners.

"The award was very meaningful to me [because] I highly admire and respect Loretta Ford," Melnyk told ADVANCE. "I consider her one of the most pioneering and passionate nurses in our history."

Melnyk received the award on the basis of her initiatives to promote mental health care for children and teens. In 2001, she established NAPNAP's KySS (Keep your children/yourself Safe and Secure) program, a national initiative to improve the mental health of children and teens. She still serves as chairwoman of the project.

"So much more is needed in terms of funding and resources to continue to make progress in this area [because] childhood is the foundation for the rest of life," Melnyk said.

"Integration of mental and physical health is key to a brighter future for our children."

August 2008

At the American Medical Association's (AMA) recent annual meeting, several state delegations proposed resolutions seeking to limit NP education and practice. Four resolutions introduced to the House of Delegates (HOD) were potentially damaging to NPs and prompted a response from national NP groups.

Resolution 13, "Physician Employment by a Physician Extender," called for the AMA to define ethical boundaries applicable to supervising or collaborating physicians who are employed by NPs.

Resolution 214, "Doctor of Nursing Practice," would have required physician supervision for NPs who earn the doctorate of nursing practice degree.

Resolution 303, "Protection of the Titles 'Doctor,' 'Resident' and 'Residency,'" would have limited the use of these terms to physicians, dentists and podiatrists.

Resolution 716, "AMA Model Agreement with Advanced Practice Nurse Clinicians, Nurse Practitioners and/or Clinical Nurse Specialists," recommended that collaborative agreements address the "quality of care, continuity of care, and scope of practice" provided by NPs.

Another resolution sought to restrict the ability of NPs to practice in retail health clinics. A resolution by the Kansas Medical Society called for close monitoring of retail health clinics to "protect the health and well-being of patients." All of these resolutions can be found on AMA's Web site, at www.ama-assn.org/ama/pub/cat egory/18584.html.

In a visible sign of unity not seen in recent history, seven national nurse practitioner groups got together to quickly draft a response to these attacks: the American Academy of Nurse Practitioners, the American College of Nurse Practitioners, the Association of Faculties of Pediatric Nurse Practitioners, the National Association of Nurse Practitioners in Women's Health, the National Association of Pediatric Nurse Practitioners, the National Conference of Gerontological Nurse Practitioners and the National Organization of Nurse Practitioner Faculties.

The groups wrote a strongly worded position statement on three important issues: the doctorate of nursing practice (DNP), NP certification and use of the title "doctor."

"The DNP degree more accurately reflects current clinical competencies and includes preparation for the changing health care system," the groups wrote. The document also stated that the NP groups do not support a National Board of Medical Examiners (NBME) certification for DNPs and that the title "doctor" is earned by many and should not be reserved for physicians alone.

In addition to the action by the NP groups, the American Nurses Association (ANA) submitted letters to the AMA. In response to Resolution 214 concerning physician supervision of DNPs, the ANA wrote: "State law, state boards of nursing and the nursing profession itself are the only appropriate entities to regulate the practice of nursing. It is not appropriate for the AMA or the medical profession to regulate the practice of nursing, any more than it would be appropriate for the nursing profession to attempt to regulate physicians and the practice of medicine."

In response to Resolution 303 about titles, the ANA wrote: "Those who have earned a doctorate degree may be called a 'doctor.' There is no legitimate reason to exclude nurses from this practice."

Eileen Shannon Carlson, associate director of government affairs for the ANA, told ADVANCE that four nursing groups were granted observer status for the AMA HOD meeting. Carlson was one of the "observers." She reported "much discussion questioning the ability of DNPs to provide independent patient care - ignoring the fact that many NPs already do so." The AMA resolved to oppose the NBME DNP certification and resolved to seek collaborative agreement requirements for DNPs.

The HOD decided not to seek restriction on the use of the titles "doctor," "resident" and "residency." However, the HOD did adopt a resolution that would make misrepresenting oneself as an MD or DO punishable as a felony. Carlson said this was a particularly heated topic among the delegates, with some claiming the term was coming under "assault by wannabes."

The HOD also voted to adopt a resolution banning tobacco from stores in which retail health clinics operate. Several states, including Illinois and Rhode Island, have tried to pass similar legislation, and the AMA apparently hopes this resolution will support those efforts. Retail health operators, as well as NPs, believe that a ban on tobacco sales in stores with retail health clinics could only harm patients, removing their access to care and potential for receiving smoking cessation education.

Resolutions approved or adopted by the AMA HOD are statements of proposed policy that have no legal or regulatory bearing on NP practice. But they set the stage for future legislative action planned by state medical associations and the AMA. The flurry of resolutions at this year's HOD meeting is a sign that NP organizations must act now to prepare their own legislative campaigns.

The American Geriatrics Society (AGS) - a physician-dominated group focused on the care of older adults - recently named Valisa Saunders, NP, its Clinician of the Year. This was the first time the AGS has given the award to someone who is not a physician. The award is given to a health care provider who shows extraordinary devotion to patients and to the advancement of quality geriatric care.

Saunders has won numerous awards for clinical excellence. She helped pioneer the role of the gerontologic NP in Hawaii through her efforts to develop enabling regulations for nurse practitioners, blending leadership and clinical roles and her work with students from the University of Hawaii. Her other projects include work on a Medicare risk screening program, a multidisciplinary clinic for diabetes patients with limb problems, a dementia research program and a contract to provide neighbor island geriatric assessment clinics to Native Hawaiians using gerontologic NPs. She also developed and established a nursing home rounding program that included nurse practitioners.

August 2008

Missouri governor Matt Blunt recently signed into law a bill that provides the state's nurse practitioners with prescriptive authority for controlled substances (CS) on schedules III, IV and V.

"We are very excited about our success with controlled substance privileges for [NPs] in Missouri," said Jill Kliethermes, NP, chief executive officer of the Missouri Nurses Association.

But, Kliethermes notes, it is important for NPs in Missouri to know that although the law goes into effect Aug. 28, NPs will not be able to prescribe until rules and regulations are drafted and implemented, a process that could take a year or more.

Perhaps helpful to this bill's passage was amended language about electronic tracking of pseudoephedrine purchases, which the governor publicized heavily as a good step in the fight to thwart methamphetamine lab operation.

The passage of this law in Missouri reduces the number of states without CS authority for NPs to two. Florida and Alabama still do not allow NPs to prescribe any controlled substances. Hawaii and Georgia have passed CS legislation but have not completed rules and regulations to implement these laws.

August 2008

Florida NPs are pressing on with efforts to remove practice barriers. They organized or influenced the introduction of several bills in this year's legislative session and will continue working on these issues. Senate Bill 972 and companion House Bill 515 would have allowed Florida NPs in underserved areas to prescribe drugs on schedules II through V under collaborative agreements with supervising physicians. Both bills died in committee.

Florida NPs have been prescribing medications, with the exception of scheduled drugs, since 1987. Florida is one of only two states that do not allow NPs to prescribe scheduled medications for patients who require them.

Mai Kung, an NP who is a DNP student and member of the Florida Nurses Association (FNA) and the Tallahassee chapter of the Council of Advanced Practice Nurses, said a published study gave Florida a grade of "F" for consumer choice based on NP regulation (Lugo NR, et al. Ranking state NP regulation: practice environment and consumer healthcare choice. American Journal for Nurse Practitioners. 2007;11[4]:8-24).

"This legislation will not only remove barriers to practice and allow NPs to prescribe controlled substances, it will improve patients' access to health care. Patients have a right to receive timely, appropriate medications to treat their health conditions," Kung told ADVANCE. Kung wrote an editorial about NP prescribing for Talahassee.com that asked, "Why decline access to better care?"

The determination and energy of Florida NPs has not diminished despite repeated disappointments as they work for controlled substances prescribing.

"It's about the 14th year we have been blocked on this ... yet we still continue to serve the health care needs of Floridians!" Jean Aertker, NP, told ADVANCE as the legislative session neared a close in early May. She is treasurer and past president of the Florida Nurse Practitioner Network (FNPN).

The FNA, the Florida Coalition of Advanced Practice Nursing and the FNPN are part of the Coalition for Advanced Practice Nursing, which is working with lobbyists for the passage of these bills.

NASHVILLE - Nearly 1,500 pediatric NPs were both entertained and informed when the National Association of Pediatric Nurse Practitioners (NAPNAP) held its 29^thannual conference here in April.

Appropriately, the keynote address was delivered by one of country music's biggest stars, Naomi Judd. And although she didn't sing a single note, she provided a decidedly entertaining ceremonial opening for the meeting. This former ICU nurse-turned-Grammy winner walked among the audience to share her own medical struggles with hepatitis C and reminded them that the disease "will kill four times more people in the United States this year than AIDS will." Judd's disease is in remission, and she attributes it to integrative therapies (including traditional medical interventions) and a focus on the power of positive thought.

Also at the meeting, NAPNAP members elected new officers, who began their respective positions this month. They are as follows:

• President-elect - Michelle Beauchesne, NP
  
• Treasurer - Nancy Banasiak, NP
  
• Chapters' coordinator - Melissa Reider-Demer, NP
  
• Professional Issues - Andrea Kline, NP
  
• Nominations Committee - Marguerite DiMarco, NP.

The 2009 annual conference for NAPNAP is scheduled for March 19-22 in San Diego.

Nurse practitioners in the division of nephrology and hypertension at Henry Ford Health System (HFHS) in Detroit recently completed a study that further documented the effectiveness of nurse practitioner care.

The results showed that nurse practitioners provided care at least equal to that provided by nephrologists in reducing hypertension in chronic kidney disease patients.

"Our patients are initially seen by a nephrologist, and, once their chronic kidney disease diagnosis is established, they are referred to a nurse practitioner. ? The nurse practitioner was still able to lower their blood pressure by 6%," said Naima Ogletree, NP and comanager of the chronic kidney disease clinic at HFHS, in an interview with MedPage Today.

Olgetree reported the study's findings to the National Kidney Foundation at its annual conference: More than half (50.3%) of the 487 patients achieved controlled blood pressure in this NP-managed clinic, which is comparable to results of other kidney disease clinics. At baseline, 43.4% of the patients had controlled blood pressure.

Managing blood pressure is important in chronic kidney disease patients because it is closely linked to the disease as both a cause and a consequence. "[The care provided by] a nurse practitioner is very comparable to the care you would get" from a nephrologist, Ogletree said. "You will get effective management from a nurse practitioner as well."

The question remains whether nurse practitioner care was the cause of the lowered blood pressure in patients with chronic kidney disease. "We're not quite sure - we don't know if it's the nurse practitioner or the fact that we were seeing them more frequently. That is something we plan to look at in a future study," Ogletree told ADVANCE. She said the study is a starting point, and she will continue to research how well NPs provide care at the NP-managed chronic kidney disease clinic of the HFHS.

The table accompanying this report shows that when compared with physicians, NPs provided chronic kidney disease care that was just as effective in reaching specific targets of chronic kidney disease care.

Nurse practioners achieved a victory in Oklahoma that will lead to better patient care. After a months-long battle, NPs in Oklahoma are now able to prescribe 30-day supplies of schedule III to V drugs. The previous regulations allowed NPs to prescribe these drugs for only 7 days.

"This created some big problems for our patients - caused them needless expense in additional copays and visits," said Mary Petermann Garnica, NP, legislative chairwoman of Oklahoma Nurse Practitioners (ONP). The state board of nursing unanimously approved the regulation.

Grassroots efforts in Oklahoma also helped halt the progress of legislation that would have restricted NP practice in the state. Two bills were introduced during the 2008 legislative session to control practice in NP-led clinics and retail health clinics.

Senate bill 1523, titled the "Retail Health Clinic Act," would have required that all retail health clinics be owned by physicians and that signage be displayed if a physician was not on the premises. The bill would have limited each physician's supervisory scope to "no more than two full-time nonphysician practitioners or four part-time nonphysician practitioners at any one time."

Senate bill 1638, titled the "Nonphysician Practitioners Supervision Act," would have required that physicians perform various supervisory acts in NP-run clinics, including being on site for at least 1 half-day per week. Under current law, no physician supervision is required for NPs in Oklahoma.

"This would have substantially driven up operating costs to NP practice owners and forced many of them to close their practices," Garnica said. "Our members got very active over this and contacted their senators. We believe that was an important factor in these bills not going anywhere." Both bills died in a Senate rules committee.

"Had they passed, there would have been an even greater health care access problem in our state," Garnica commented. "We have a growing number of NPs who are in independent practice in rural areas."

Garnica said the language of SB 1638 was inspired by Resolution 8 of the American Medical Association (AMA) House of Delegates, which aims to move regulation of NPs from state boards of nursing to state medical boards. SB 1523 was modeled on AMA resolutions for the regulation of retail health clinics, which has inspired similar legislation in other states.

At press time in June, nothing further had been introduced in the Legislature. Garnica said the ONP will keep a close watch to the end of the session to be sure no amendments are added to any bill to affect NP practice.

RETAIL HEALTH NEWS: A bill that would severely limit the ability of retail clinics to operate in drug stores was derailed in Rhode Island.

Senate bill 2356 stated that no store operating a clinic would be granted a license to sell tobacco products.

Similar legislation was proposed in Illinois, as reported in the May issue of ADVANCE. If the law had passed, drug stores would be reticent to open clinics because they would have to remove all tobacco products from their shelves and therefore would lose revenue. According to the Rhode Island General Assembly Web site, a Senate committee recommended the measure be "held for further study." The bill was sponsored by the Rhode Island Medical Society.

"Generally speaking, the primary care physicians and urgent care center physicians are totally opposed to [retail health clinics] at any level and in any form," said Denise Coppa, NP, nurse practitioner council cochairwoman for the Rhode Island State Nurses Association.

Nurse practitioners in Tennessee have been involved in a number of issues this legislative session and are also working with the state's medical board on new regulations for NP practice.

The Tennessee Medical Association (TMA) has drafted rules for the state board of medical examiners that would increase oversight of NPs and other medical professionals by physicians; NPs are working to scale back that oversight ability.

"The way the Tennessee law is written, the standards would have to be accepted by both the board of medical examiners and the board of nursing," explained Meredith Sullivan, lobbyist for the Tennessee Nurses Association (TNA).

The TMA is also working with the Convenient Care Association (CCA), which represents retail health clinics, to discuss concerns the medical association has about retail health clinics. The TMA plans to meet with the TNA, the CCA, the Tennessee Association of Physician Assistants, the Tennessee Retail Association and retail clinics with sites in Tennessee.

Bills that could have adversely affected NP practice did not advance through the Legislature. One bill stemmed from passage of the Smoke-Free Tennessee program in 2007. This law prohibits smoking in workplaces and most restaurants. It prompted a 2008 bill intended to protect the health of consumers, but it may have an unintended effect of keeping convenient care clinics from operating. Similar to legislation proposed in Rhode Island and Illinois, SB3502 and HB3205 would prohibit the sale of cigarettes at any place of business where health care is provided. This would keep retail health clinics out of stores.

The bills were not scheduled for consideration in the Senate or the House, Sullivan said.

A victory for NPs in Tennessee this year was legislation that allows NPs to co-own a professional limited liability corporation with physicians. The bill was signed into law and became effective April 1.