Closing the Gaps in 2009 with Nursing Board-Granted Prescriptive Authority

1. Closing the Gaps in 2009with Nursing Board-Granted Prescriptive Authority www.cnaptexas.org

2. Update Negotiations between APN and Medical Organizations • Negotiations began in February and ended on September 20, 2008. • Almost had a deal. • In the end, TMA would not agree to end site-based restrictions on physicians delegating prescriptive authority.

3. Texas APNs’ Legislative Initiative in 2009

4. 2009 Legislative Agenda • In 2009 Texas Legislative Session, APRNs will take action to close gaps • Change diagnosis & prescribing from physician-delegated to granted by the Board of Nursing. • Basis for legislation will be APRN Model Language (based on August 2008 APRN Consensus Model for APRN Regulation, www.ncsbn.org/170.htm) Nursing Board-Granted Prescriptive Authority

5. Nursing Board-Granted Prescriptive Authority Explaining Nursing Board-Granted Prescriptive Authority to your Texas Legislators. It will help fill gaps in Texas health care.

6. Health Care Gap #1 Nurse Practitioners per 100,000 Population U.S. and Texas, 1990-2007 25 20 15 Nurse Practitioners 10 Texas NPs U.S. NPs 5 0 1990 1992 1993 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year The gap between US and Texas ratios of NPs per 100,000 population

7. Health Care Gap # 2 ACCESS GAP The gap between number of Primary Care Providers and need for Primary Health Care among underserved populations.

8. Medically Underserved Counties Pink – Whole County (178) Blue – Partial County (48) White – Not designated (28)

9. Primary Care Gap • Population of Texas is: • growing • aging • becoming more diverse • Declining number of physicians entering primary care Source: Health Professions Resource Center (September 2007) Supply Trends Among Licensed Health Professions: Texas 2980 – 2007. www.dshs.state.tx.us/CHS/hprc.

10. GAO Report on Primary Care Professionals Primary Care Gap “In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians.”

11. Primary Care Gap “Research shows that absent a PA or NP, some populations would have no access to health care. PAs and NPs go into primary care in greater percentages than physicians,…” Roderick Hooker, M.D. Director of Research, Rheumatology Section, Medical Service Department of Veterans Affairs Dallas VA Medical Center February 12, 2008 US Senate Health, Education & Labor Committee

12. Primary Care Gap Nurse Practitioners (NPs) are the fastest growing group of primary care providers. Source: US Government Accountability Office (February 12, 2008). Primary Care Professionals: Recent supply Trends, Projections, and Valuation of Services. GAO-08-472T, www.gao.gov/new.items/d08472t.pdf.

13. Closing Gaps Requires Change • The U.S. focused on getting more primary care physicians since the 1960s. • It is not working • Having an affordable, quality health care system requires a new approach.

14. Closing the Gaps Closing primary care gaps starts with asking the right policy questions.

15. The Right Policy Question • What is the right mix of health care providers? Our nation can no longer afford the most highly educated & expensively trained professionals to provide healthcare services that others can provide with comparable outcomes.

16. The Right Policy Question • What is the right mix of health care providers? • Texas can educate at least 8 APNs for the cost of producing 1 physician. • Those APNs can practice a cumulative 32 years before the physician completes a residency program.

17. The Right Policy Question • What will increase numbers of primary care APNs without costing $$? • Change Texas laws & rules to fully integrate NPs & other primary care APNs into the health care system. Research shows a strong correlation between states with supportive practice environments for NPs and the number of NPs

18. Closing the Gap 3. What can Texas do to improve efficiency of the current health workforce and improve access to health care? • Simplify Texas laws regarding APN prescriptive authority. • Current prescriptive authority laws for APNs are restrictive, difficult to enforce, and impede access to care.

19. Best Way to Simplify Rx Authority Nursing Board-Granted Prescriptive Authority Amend Nursing Practice Act to allow Board of Nursing to grant APNs authority to diagnose and prescribe.

20. What Changes with Board-Granted Rx Authority? Nursing Board-Granted Prescriptive Authority • The APN may make a medical diagnosis without physician delegation. • The APN may prescribe drugs and medical devices without physician delegation. • CRNAs may order the drugs & devices needed to provide anesthesia without physician delegation.

21. What Changes? Nursing Board-Granted Prescriptive Authority • Eliminates Rx site-based restrictions • Removes Rx physician supervision • Allows APNs full Rx authority: • Removes restrictions on controlled substances, Schedules III-V • Allows APNs to Rx schedule II drugs

22. Board-Granted Prescriptive Authority is NOT: Nursing Board-Granted Prescriptive Authority • Practicing without physician collaboration or consultation, • Self-employment, or • Owning your own practice.

23. What Does Not Change? Nursing Board-Granted Prescriptive Authority • Regulation by the Board of Nursing – Texas BON already has sole authority to regulate APNs. • Except for diagnosing & prescribing, most of APN practice is already not physician delegated, including ordering & interpreting diagnostic tests. • Collaboration and consultation with physicians is a basic tenet of APN practice.

24. Board-Granted Rx Authority • In 33 states APNs obtain authority to prescribe from Board of Nursing. • 11 states require no collaboration with a physician • 22 states require a collaborative agreement signed by a physician

25. Closing the Gaps • Patient outcomes in states in which APNs’ Rx authority comes from the Board of Nursing are the same as in states, such as Texas, that require physician delegation.

26. Closing the Gaps • APNs continue to collaborate with physicians whether collaboration is required by law or not. Collaboration is a basic tenet of APN practice and always an integral part of practice.

27. Closing the Gaps • National Council of State Boards of Nursing approved model APRN legislative language in August 2008. The model language states:

28. NCSBN Model APRN Language The scope of an APRN includes, but is not limited to, performing acts of advanced assessment, diagnosing, prescribing and ordering. APRNs may serve as primary care providers of record. APRNs are expected to practice as licensed independent practitioners within standards established and /or recognized by the board….

29. SUMMARY • Ask the right policy questions to: • move Texas toward more efficient utilization of the health care workforce; and • Close the gap in numbers of primary care APNs in Texas versus US. • Change Texas laws to support full integration of APNs in the primary care workforce.

30. SUMMARY • Texas needs more primary care providers & the need is growing. • Improving Texas laws will allow more efficient practice for APNs and physicians. • Improving Texas APN laws will attract more primary care providers to Texas and improve access to care.

32. What Will It Take to Get Nursing Board Granted Prescriptive Authority for APNs? • 76 votes in the House • 21 votes in the Senate

33. Do Your Fair Share Contribute $30 /month to CNAP and $15 /month to RN/APN PAC ( Total = 1 hour of your salary / month) Visit /contact your legislators 4 times each year Spread the word and recruit 4 colleagues to do the same

34. Are you taking a free ride? 95% of APNs in Texas 5% of APNs are pulling the load

35. Nursing Board-Granted Prescriptive Authority Help CNAP Make It Happen www.cnaptexas.org