A Critical Role for Better Population Health Management
Licensing limitations and barriers to practice are problematic for an industry struggling to meet the nation’s ever-increasing need for healthcare. Health systems’ population health initiatives continue to drive the need for more practitioners, yet the Health Resources and Services Administration predicts there will be a shortage of 20,400 primary care physicians by 2020. Ironically, the same licensure laws that ensure public safety inadvertently deny the public much-needed healthcare by trained professionals due to unnecessary licensing barriers.
In 2010, the National Academy of Medicine (formerly the Institute of Medicine) released The Future of Nursing, Leading Change, Advancing Health. Included in this special report was a key message: nurses should practice to the full extent of their licensure and training. Nearly a decade later, this vision still hasn’t been achieved. Regulatory barriers to practice remain, particularly for advanced practice registered nurse (APRN) roles: certified advanced registered nurse practitioner (ARNP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS).
This article explains the critical role APRNs play in population health management and outcomes improvement, investigates unnecessary barriers to practice and their many harmful consequences, and explores one hopeful solution.
A Critical Population Health Role: Clinical Nurse Specialists
The clinical nurse specialist plays an extremely important role in addressing the healthcare practitioner shortage and meeting ever-increasing population health demands.
Prepared by education, training, and certification at an advanced level to provide care for patients, CNSs have been a part of healthcare in the U.S. for more than 60 years. The need for specialists in nursing first appeared in the literature in the 1900s. Dr. Hildegard Peplau is credited with first describing the CNS role in 1965, describing the need for an advance practice nurse with expertise in care of complex patients and expertise in nursing practice.
Clinical nurse specialists are expert clinicians with advanced education in a specialized area of nursing:
- Population (pediatrics, geriatrics, women’s health).
- Setting (critical care, emergency department, acute care).
- Disease or medical sub-specialty (diabetes, oncology).
- Type of care (psychiatric or rehabilitation).
- Type of problem (pain, wound, stress).
The hallmarks of effective CNS practice include the comprehensive management of patients for whom they are responsible, the provision of expertise and support to nurses caring for patients at the bedside, the use of best practice and evidence-based care to improve outcomes, and facilitation of practice changes throughout the organization. The value of the CNS and the population health outcomes CNSs can help organizations achieve are well documented:
- Less frequent ED visits and decreased cost for children with asthma managed by a CNS.
- Decreased cost of care for low birth weight infants cared for by a CNS. One study, a 2001 randomized, controlled clinical trial showed that the group receiving home care from a CNS saved 750 hospital days, saving $2.9 million dollars.
- Higher patient satisfaction at CNS staffed clinics when compared to other staffing approaches.
- Improved access to wellness and preventative care, reducing overall costs of care for employers.
- Improved mental health and reduced incidence of depression.
- Decreased incidence of hospital acquired conditions (HACs).
- Sustained reductions in incidence of restraint and seclusion.
- Reductions in unnecessary readmissions.
- Reduced costs of care for patients with chronic conditions.
- Reduced length of stay (LOS).
Several healthcare organizations employ CNSs, who are active contributors within their organizations, working with their colleagues and interdisciplinary teams to improve organizational and patient outcomes:
- Texas Children’s use of evidence-based order sets reduced the cost per patient with order set utilization by $2,401 and demonstrated an 8.4-day difference in average LOS.
- Piedmont Healthcare decreased mortality for patients with severe sepsis and septic shock by 5.8 percent, while also decreasing total inpatient LOS by 2.5 percent and achieving an 8.2 percent variable cost reduction, equating to $4.3 million saved in one year.
- Allina Health’s nurse-driven protocol for post-op atrial fibrillation has reduced ICU LOS by two days and reduced ICU readmission by 5.9 percent, saving $1.5 million.
The Problem: Barriers to Practice (Unnecessary Licensing Limitations)
There are more than 267,000 APRNs in U.S., and many are unable to practice to the full extent of their education, training, and competency. APRNs have fully independent practice in just 20 of 50 states. Despite sufficient evidence that demonstrates the positive outcomes of CNS practice, ample evidence supporting the positive outcomes of our advanced practice peers, and a relative lack of evidence that expanded APRN practice is in any way unsafe, many CNSs, ARNPs, CNMs, and CRNAs, are unable to practice to the full extent of their education, training, and competency due to licensing limitations.
The purpose of nurse licensing is to protect the public from harm, establishing minimum standards for safe-entry level practice. Nursing is regulated as it is a profession that poses the risk of harm to the public if the individual performing the work is not adequately prepared or competent. State boards of nursing (BONs) hold responsibility for protecting the public by overseeing the safe practice of nursing, protecting the public from unsafe, incompetent, or unethical practice of nursing. Historically, common definitions and uniformity in educational, BON, and state regulations has been lacking. While the primary purpose of licensure is to protect the public, licensure, or lack thereof, can inadvertently limit APRN practice, APRN portability, and access to care, even when the practice of APRNs has been confirmed to be safe and beneficial to the public.
For example, I’ve been a member of the nursing workforce for more than 20 years, and have held registered nurse licenses in both Oregon and Washington for more than 15 years. Upon completion of my CNS program, graduate degree, and national board certification, I obtained a CNS license from Oregon. This license legally provides me fully independent practice. While I enjoyed fully independent practice Oregon, I wasn’t allowed to do the same in Washington, as they did not license CNS as advanced practice nurses (the only advanced practice nurses in Washington lacking licensure permitting fully independent practice).
In 2007, CNSs in Washington initiated focused work to obtain inclusion in the State’s advanced practice rules. It wasn’t until January 8, 2016, that the State BON approved a revision to the State’s rules, including CNSs as advanced practice nurses. The path to advanced practice licensure for CNSs in Washington is described in Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. While this change is incredibly important for CNSs in Washington and the patients and organizations they serve, it is merely one change in a long list of changes that are needed nationwide.
The Many Consequences of Licensing Limitations and Barriers to Practice
Unnecessary limitations on the practice of CNS and other APRNs, negatively impact APRNs and the patients and communities they serve in countless ways:
- Delayed access to clinicians.
- Decreased access to care, particularly primary care and care in rural areas.
- Limits in the labor supply.
- Increased costs of services, due in part to reduced competition which benefits consumers.
- Loss of potential revenue for healthcare organizations and APRNs. APRNs, including CNSs, are eligible for reimbursement from CMS. However, to bill for services, the APRN must be authorized to provide the services in accordance with state law.
Limitations on APRN practice impair their ability to provide care, reduce the ability of healthcare organizations to provide quality care, and prevent patients from accessing APRNs.
A Promising Solution: Uniform Regulations
To remedy the lack of uniformity in APRN regulation and the myriad of issues this causes, the National Council of State Boards of Nursing (NCSBN), a national organization through which BONs act together, is encouraging boards of nursing to adopt the APRN Consensus Model. APRN Consensus provides for uniformity in the regulation of the four APRN roles, setting standards in four areas:
- Licensure—the granting of authority to practice.
- Accreditation—the review and approval of educational degree or certification programs in nursing/nursing related problems.
- Certification—formal recognition of knowledge, skills, and experiences.
- Education—formal preparation of APRNs in graduate or post graduate education programs.
While the NCSBN has substantial influence, the state-level BONs are responsible for regulating nursing practice. Implementation of APRN Consensus has been slow. The goal for implementation was 2015. To date, only 14 of 50 states have fully implemented APRN Consensus.
Fortunately, many organizations recognize the importance of removing barriers to practice. For example, the U.S. Department of Veterans Affairs (VA) amended its medical practice regulations to permit full practice authority to APRNs employed by the VA (more than 6,000) when they are acting within the scope of their VA employment, regardless of state or local law restrictions. Previously, the work APRNs were permitted to perform varied widely depending upon the licensure rules in their state of practice, resulting in barriers to practice and negatively impacting patient access to qualified, effective clinicians. According to the VA, APRNs are an underutilized resource—by removing the scope of practice barriers associated with variable state licensing requirements, the VA hopes to improve veteran access to timely, efficient, effective, and safe primary care.
But until APRN Consensus is fully implemented nationwide, access to care that is safe, clinically effective, and cost effective will continue to be impaired.
Removing Barriers to Practice Will Improve Population Health Management
Removing unnecessary barriers to practice and allowing APRNs to practice to the full extent of their education, training, and competency (as envisioned by the National Academy of Medicine nearly a decade ago), will result in better use of the nation’s 267,000 APRNs, reduce nationwide shortages in primary care, and help healthcare organizations improve the cost of care, individual patient outcomes, and population health management.
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