Challenges faced by Novice NPs. New Role
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1. Survival Tips for the Novice NP Katie de Leon-Demare NP, MN, FNP
2nd Annual NPAM Conference
October 2, 2010
2. Challenges faced by Novice NPs New Role & Responsibilities:
Exception Drug Status
Referrals & Consultations
Third Party Payors & Insurance Companies
Liability/ Risk Management
3. Challenges faced by Novice NPs (Cont’d) New Team:
Who are your champions?
Who needs to learn about the role?
Who needs to be convinced?
New Practice Environment:
What are expectations of the NP?
What are changes are needed to integrate NP?
4. Issues to consider in your first NP position (Szanton, S. et al, 2010, JAANP) Patient Factors
Success requires intention !
5. Issues to consider in your first NP position (Szanton, S. et al, 2010, JAANP) Patient Factors
Acuity level match with your comfort level?
Available resources that impact your ability to provide care?
What needs can be met with addition of an NP?
6. Issues to consider in your first NP position 2. Colleague factors:
Learning Practice Styles
Learning scopes of practice & overlap
Collaborative practice vs. supervision
7. Degrees of Collaboration
8. Issues to consider in your first NP position 3. Clinic Factors
What is their past experience with NPs in provider mix?
What are productivity expectations?
Does mission of the clinic match with values of the NP?
Scheduling: NPs different from MDs
9. Issues to consider in your first NP position 3. Clinic Factors
Scheduling: NPs different from MDs
Sick vs. well visits
Follow-up vs. Rx refills
Well vs. high-needs patients
Balance and pace new intakes
10. Issues to consider in your first NP position 3. Clinic Factors
Front desk staff
Rostering patients with the NP
Educate staff of limits of your practice
Prescribing limitations, forms, procedures
Accurate & Consistent message when booking patients:
“Care from the NP will not differ from that of the Doctor”
11. Issues to consider in your first NP position 3. Clinic Factors:
Regular meetings with manager
Monthly, 3 months, 6 months - annual
Regular Clinic Rounds with the team
Public relations: signs, pamphlets, stamp
Network with NPs in the region
12. Making the transition from RN to NP Letting go
Delegate nursing function/services
Teach to maximize RN role within your setting
The Strong Model
13. Strong Model of Advanced Practice Ackerman et al (1996). American J of Critical Care, 5: 68-73
14. Issues to consider in your first NP position Survivor Tools developed by the WRHA:
NP Implementation ToolKit
NP Learning Needs Assessment
Look under advanced practice nursing workshop 2008
15. Overcoming Prescribing Stumbling Blocks Navigating EDS
Exception Drug Status (EDS)
-list of drugs approved as eligible benefits under Pharmacare
Therapeutics Committee, MB Health
Minister of Health gives final approval
16. Overcoming Prescribing Stumbling Blocks Navigating EDS
common products: aerochambers, test strips
common antibiotics, OCPs, anti-hypertensives
drugs used when alternative tx not effective or not tolerated
e.g. Azithromycin, Levoquin, Macrobid,
Rx should include “ meets EDS criteria”
17. Overcoming Prescribing Stumbling Blocks Navigating EDS
EDS Part 3
-drugs considered for reinbursement based on specific criteria & require request and approval
PPIs, Celebrex etc, Actonel etc, Mirena, Lantus
EDS: WPG (ph)788-6388 (Fax) 942-2030
Outside WPG: (ph) 1-800-557-4303
Identify collaborating physician
Once approved, NPs can refill prescription
Appeals process through Therapeutics Committee
18. Overcoming Prescribing Stumbling Blocks Navigating EDS
EDS Part 3
- Some products not covered: appetite suppressants, smoking cessation products, ED products, vaccines
Patients can pay out of pocket
3rd party insurance
19. Overcoming Prescribing Stumbling Blocks Navigating EDS
EDS list is always changing and updated
20. Overcoming Prescribing Stumbling Blocks Narcotics, Benzo’s, Controlled substances
Some tips for efficiency & ease
Meeting with collaborating MD & pt & you
Set up schedule/contract for refills
Advise front desk staff
21. Overcoming Prescribing Stumbling Blocks Practical Tips:
Meet your community pharmacists
Facsimile RX form template – available through CRNM
RX files Drug Comparison Charts
22. Third Party Payors: We’re getting there
Manitoba Employment & Income Assistance Medical Forms
Worker’s Compensation Board
MPIC (September 2010)
23. Third Party Payors: We’re getting there In progress: Discuss with case worker on case by case basis
Insurance Companies (GWL)
Not yet: Most federal government forms
Dept of Veterans Affairs
24. Diagnostics: Avoiding Pitfalls Pulmonary Function Tests (also making progress)
25. Consultations & Referrals Consultation
Payable and auditable service
specialist takes over care
Can only bill for the visit
26. Consultations & Referrals Work in progress
Develop a roster of specialists who take consults from NPs
If this is first time for specialist to receive NP consultation provide your billing number and information.
27. Tariff Codes Specific to RN Extended Practice 8110 -Health History
Oral hx only
15 minute period
15 minute period
8100 Communication initiated by pt/family
8101 Communication initiated by practitioner
28. Tariff Codes Specific to RN Extended Practice: Consultations 8107 - from allied health
8108 -to allied health
e.g. NP ? O.T. 8139 -from family M.D.
e.g. home care issues
8140 - NP ? NP
e.g. NP in specialty practice
29. Tariff Codes Specific to RN Extended Practice 8109
Case management outside of office visits
E.g. meeting with teacher, public trustee, home care case worker & family,
30. Tips on billing: RN Extended Practice Attach notations to procedures:
site, number of lesions
Attach notations on special situations:
e.g. Pre-ops - Document procedure, surgeon & OR date
31. Tips on billing: RN Extended Practice Develop a list of common tariffs
Remember you can have more than one tariff in a clinic visit
Discuss unique RN EP codes with billing clerk
Make your work count !!!
32. Liability Insurance Employer covers general vicarious liability insurance
CRNM/CNA provides liability insurance for NPs ($5million)
What is not covered: Disciplinary costs
AON Reedhouse (CNPI)
33. Unionization Manitoba Nurses’ Union with your region or health facility
MNU local 141 – WRHA community/ER NPs
NP salary scale, Protected time, on-call, shift differential
34. Lessons learned NPs need champions & liaisons.
Overlap of roles need to be clarified.
Talk about liability.
Policies & procedures need to be reviewed.
An informed system promotes utilization and acceptance.