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The Future of Nursing: Leading Change, Advancing Health
3
Transforming Practice
Key Message #1: Nurses should practice to the fullextent of their education and training.
Patients, in all settings, deserve care that is centered on their uniqueneeds and not what is most convenient for the health professionalsinvolved in their care. A transformed health care system is requiredto achieve this goal. Transforming the health care system will in turnrequire a fundamental rethinking of the roles of many health professionals, including nurses. The Affordable Care Act of 2010 outlines somenew health care structures, and with these structures will come newopportunities for new roles. A number of programs and initiatives havealready been developed to target necessary improvements in quality, access, and value, and many more are yet to be conceived. Nurses have theopportunity to play a central role in transforming the health care systemto create a more accessible, high-quality, and value-driven environmentfor patients. If the system is to capitalize on this opportunity, however,the constraints of outdated policies, regulations, and cultural barriers,including those related to scope of practice, will have to be lifted, mostnotably for advanced practice registered nurses.
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3
Transforming Practice
Key Message #1: Nurses should practice to the full extent of their education and training.
Patients, in all settings, deserve care that is centered on their unique needs and not what is most convenient for the health professionals involved in their care. A transformed health care system is required to achieve this goal. Transforming the health care system will in turn require a fundamental rethinking of the roles of many health professionals, including nurses. The Affordable Care Act of 2010 outlines some new health care structures, and with these structures will come new opportunities for new roles. A number of programs and initiatives have already been developed to target necessary improvements in quality, access, and value, and many more are yet to be conceived. Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.
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The Affordable Care Act of 2010 (ACA) will place many demands on health professionals and offer them many opportunities to create a system that is more patient centered. The legislation has begun the long process of shifting the focus of the U.S. health care system away from acute and specialty care. The need for this shift in focus has become particularly urgent with respect to chronic conditions; primary care, including care coordination and transitional care; prevention and wellness; and the prevention of adverse events, such as hospital-acquired infections. Given the aging population, moreover, the need for long-term and palliative care will continue to grow in the coming years (see Chapter 2). The increase in the insured population and the rapid increase in racial and ethnic minority groups who have traditionally faced obstacles in accessing health care will also demand that care be designed for a more socioeconomically and culturally diverse population.
This chapter examines how enabling nurses to practice to the full extent of their education and training (key message #1 in Chapter 1) can be a major step forward in meeting these challenges. The first section explains why transforming nursing practice to improve care is so important, offering three examples of how utilizing the full potential of nurses has increased the quality of care while achieving greater value. The chapter then examines in detail the barriers that constrain this transformation, including regulatory barriers to expanding nurses’ scope of practice, professional resistance to expanded roles for nurses, fragmentation of the health care system, outdated insurance policies, high turnover rates among nurses, difficulties encountered in the transition from education to practice, and demographic challenges. The third section describes the new structures and opportunities made possible by the ACA, as well as through technology. The final section summarizes the committee’s conclusions regarding the vital contributions of the nursing profession to the success of these initiatives as well as the overall transformation of the health care system, and what needs to be done to transform practice to ensure that this contribution is realized. Particular emphasis is placed on advanced practice registered nurses (APRNs), including their roles in chronic disease management and increased access to primary care, and the regulatory barriers preventing them from taking on these roles. This is not to say that general registered nurses (RNs) should not have the opportunity to improve their practice and take on new roles; the chapter also provides such examples.
THE IMPORTANCE OF TRANSFORMING NURSING PRACTICE TO IMPROVE CARE
As discussed in Chapter 2, the changing landscape of the health care system and the changing profile of the population require that the system undergo a fundamental shift to provide patient-centered care; deliver more primary as opposed to specialty care; deliver more care in the community rather than the acute care setting; provide seamless care; enable all health professionals to practice to the
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full extent of their education, training, and competencies; and foster interprofessional collaboration. Achieving such a shift will enable the health care system to provide higher-quality care, reduce errors, and increase safety. Providing care in this way and in these areas taps traditional strengths of the nursing profession. This chapter argues that nurses are so well poised to address these needs by virtue of their numbers, scientific knowledge, and adaptive capacity that the health care system should take advantage of the contributions they can make by assuming enhanced and reconceptualized roles.
Nursing is one of the most versatile occupations within the health care workforce.1 In the 150 years since Florence Nightingale developed and promoted the concept of an educated workforce of caregivers for the sick, modern nursing has reinvented itself a number of times as health care has advanced and changed (Lynaugh, 2008). As a result of the nursing profession’s versatility and adaptive capacity, new career pathways for nurses have evolved, attracting a larger and more broadly talented applicant pool and leading to expanded scopes of practice and responsibilities for nurses. Nurses have been an enabling force for change in health care along many dimensions (Aiken et al., 2009). Among the many innovations that a versatile, adaptive, and well-educated nursing profession have helped make possible are
the evolution of the high-technology hospital;
the possibility for physicians to combine office and hospital practice;
lengths of hospital stay that are among the shortest in the world;
reductions in the work hours of resident physicians to improve patient safety;
expansion of national primary care capacity;
improved access to care for the poor and for rural residents;
respite and palliative care, including hospice;
care coordination for chronically ill and elderly people; and
greater access to specialty care and focused consultation (e.g., incontinence consultation, home parenteral nutrition services, and sleep apnea evaluations) that complement the care of physicians and other providers.
With every passing decade, nursing has become an increasingly integral part of health care services, so that a future without large numbers of nurses is impossible to envision.
1
This discussion draws on a paper commissioned by the committee on “Nursing Education Policy Priorities,” prepared by Linda H. Aiken, University of Pennsylvania (see Appendix I on CD-ROM).
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Nurses and Access to Primary Care
Given current concerns about a shortage of primary care health professionals, the committee paid particular attention to the role of nurses, especially APRNs,2 in this area. Today, nurse practitioners (NPs), together with physicians and physician assistants, provide most of the primary care in the United States. Physicians account for 287,000 primary care providers, NPs for 83,000, and physician assistants for 23,000 (HRSA, 2008; Steinwald, 2008). While the numbers of NPs and physician assistants are steadily increasing, the numbers of medical students and residents entering primary care have declined in recent years (Naylor and Kurtzman, 2010). The demand to build the primary care workforce, including APRNs, will grow as access to coverage, service settings, and services increases under the ACA. While NPs make up slightly less than a quarter of the country’s primary care professionals (Bodenheimer and Pham, 2010), it is a group that has grown in recent years and has the potential to grow further at a relatively rapid pace.
The Robert Wood Johnson Foundation (RWJF) Nursing Research Network commissioned Kevin Stange, University of Michigan, and Deborah Sampson, Boston College, to provide information on the variation in numbers of NPs across the United States. Figures 3-1 and 3-2, respectively, plot the provider-to-primary care doctor of medicine (MD) ratio for NPs and physician assistants by county for 2009.3 The total is calculated as the population-weighted average for states with available data. Between 1995 and 2009, the number of NPs per primary care MD more than doubled, from 0.23 to 0.48, as did the number of physician assistants per primary care MD (0.12 to 0.28) (RWJF, 2010c). These figures suggest that it is possible to increase the supply of both NPs and physician assistants in a relatively short amount of time, helping to meet the increased demand for care.
In addition to the numbers of primary care providers available across the United States and where specifically they practice, it is worth noting the kind of care being provided by each of the primary care provider groups. According to the complexity-of-care data shown in Table 3-1, the degree of variation among primary care providers is relatively small. Much of the practice of primary care—whether provided by physicians, NPs, physician assistants, or certified nurse midwives (CNMs)—is of low to moderate complexity.
2
APRNs include nurse practitioners (NPs), certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). When the committee refers to NPs, the term denotes only NPs.
3
To get a sense of the size and proportion of the NP workforce across the country, Stange and Sampson computed the ratio of the total number of licensed NPs to the total number of primary care MDs, physician assistants, and NPs in a given area. The physician assistant share was computed similarly. These computations are for proportion and growth analysis purposes only; they are not to suggest that all NPs or physician assistants are providing primary care.
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FIGURE 3-1 Map of the number of NPs per primary care MD by county, 2009.
SOURCE: RWJF, 2010a. Reprinted with permission from Lori Melichar, RWJF.
FIGURE 3-2 Map of the number of physician assistants per primary care MD by county, 2009.
SOURCE: RWJF, 2010b. Reprinted with permission from Lori Melichar, RWJF.
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Examples of Redesigned Roles for Nurses
Many examples exist in which organizations have been redesigned to better utilize nurses, but their scale is small. As Marilyn Chow, vice president of the Patient Services Program Office at Kaiser Permanente, declared at a public forum hosted by the committee, “The future is here, it is just not everywhere” (IOM, 2010b). For example, over the past 20 years, the U.S. Department of Veterans Affairs (VA) has expanded and reconceived the roles played by its nurses as part of a major restructuring of its health care system. The results with respect to quality, access, and value have been impressive. In addition, President Obama has lauded the Geisinger Health System of Pennsylvania, which provides comprehensive care to 2.6 million people at a greater value than is achieved by most other organizations (White House, 2009). Part of the reason Geisinger is so effective is that it has aligned the roles played by nurses to accord more closely with patients’ needs, starting with its primary care sites and ambulatory areas. The following subsections summarize the experience of the VA and Geisinger, as well as Kaiser Permanente, in expanding and reconceptualizing the roles of nurses. Because these institutions also measured outcomes as part of their initiatives, they provide real-world evidence that such an approach is both possible and necessary. Of note in these examples is not only how nurses are collaborating with physicians, but also how nurses are collaborating with other nurses.
Department of Veterans Affairs5
In 1996, Congress greatly expanded the number of veterans eligible to receive VA services, which created a need for the system to operate more efficiently and effectively (VHA, 2003). Caring for the wounded from the wars in Afghanistan and Iraq has further increased demand on the VA system, particularly with respect to brain injuries and posttraumatic stress disorder. Moreover, the large cohort of World War II veterans means that almost 40 percent of veterans are aged 65 or older, compared with 13 percent of the general population (U.S. Census Bureau, 2010; VA, 2010).
Anticipating the challenges it would face, the VA began transforming itself in the 1990s from a hospital-based system into a health care system that is focused on primary care, and it also placed emphasis on providing more services, as appropriate, closer to the veteran’s home or community (VHA, 2003, 2009). This strategy required better coordination of care and chronic disease management—a role that was filled by experienced front-line RNs. More NPs were hired as primary care providers, and the VA actively promoted a more collaborative professional culture by organizing primary care providers into health teams. It
5
See http://www1.va.gov/health/.
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also developed a well-integrated information technology system to link its health professionals and its services.
The VA uses NPs as primary care providers to care for patients across all settings, including inpatient and outpatient settings. In addition to their role as primary care providers, NPs serve as health care researchers who apply their findings to the variety of settings in which they practice. They also serve as educators, some as university faculty, providing clinical experiences for 25 percent of all nursing students in the country. As health care leaders, VA NPs shape policy, facilitate access to VA health care, and impact resource management (VA, 2007).
The results of the VA’s initiatives using both front-line RNs and APRNs are impressive. Quality and outcome data consistently demonstrate superior results for the VA’s approach (Asch et al., 2004; Jha et al., 2003; Kerr et al., 2004). One study found that VA patients received significantly better health care—based on various quality-of-care indicators6—than patients enrolled in Medicare’s fee-for-service program. In some cases, the study showed, between 93 and 98 percent of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84 percent (Jha et al., 2003). In addition, the VA’s spending per enrollee rose much more slowly than Medicare’s, despite the 1996 expansion of the number of veterans who could access VA services. After adjusting for different mixes of population and demographics, the Congressional Budget Office determined that the VA’s spending per enrollee grew by 30 percent from 1999 to 2007, compared with 80 percent for Medicare over the same period.
Geisinger Health System7
The Geisinger Health System employs 800 physicians; 1,900 nurses; and more than 1,000 NPs, physician assistants, and pharmacists. Over the past 18 years, Geisinger has transformed itself from a high-cost medical facility to one that provides high value—all while improving quality. It has borrowed several restructuring concepts from the manufacturing world with an eye to redesigning care by focusing on what it sees as the most critical determinant of quality and cost—actual caregiving. “What we’re trying to do is to have [our staff] work up to the limit of their license and … see if redistributing caregiving work can increase quality and decrease cost,” Glenn Steele, Geisinger’s president and CEO, said in a June 2010 interview (Dentzer, 2010).
Numerous improvements in the quality of care, as well as effective innovations proposed by employees, have resulted. For example, the nurses who
6
Quality-of-care indicators included those in preventive care (mammography, influenza vaccination, pneumococcal vaccination, colorectal cancer screening, cervical cancer screening), outpatient care (care for diabetes [e.g., lipid screening], hypertension [e.g., blood pressure goal <140/90 mm Hg], depression [annual screening]), and inpatient care (acute myocardial infarction [e.g., aspirin within 24 hr of myocardial infarction], congestive heart failure [e.g., ejection fraction checked]).
7
See http://www.geisinger.org/about/index.html.
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used to coordinate care and provide advice through the telephone center under Geisinger’s health plan suspected that they would be more effective if they could build relationships with patients and meet them at least a few times face to face. Accordingly, some highly experienced general-practice nurses moved from the call centers to primary care sites to meet with patients and their families. The nurses used a predictive model to identify who might need to go to the hospital and worked with patients and their families on creating a care plan. Later, when patients or families received a call from a nurse, they knew who that person was. The program has worked so well that nurse coordinators are now being used in both Geisinger’s Medicare plan and its commercial plan.8 Some of the nation’s largest for-profit insurance companies, including WellPoint and Cigna, are now trying out the approach of employing more nurses to better coordinate their patients’ care (Abelson, 2010). As a result, an innovation that emerged when a few nurses at Geisinger took the initiative and changed an already well-established program to deliver more truly patient-centered care may now spread well beyond Pennsylvania. Geisinger was also one of the very first health systems in the country to create its own NP-staffed convenient care clinics9—another innovation that reflects the organization’s commitment to providing integrated, patient-centered care throughout its community.
Kaiser Permanente10,11
As one of the largest not-for-profit health plans, Kaiser Permanente provides health care services for more than 8.6 million members, with an employee base of approximately 165,000. Kaiser Permanente has facilities in nine states and the District of Columbia, and has 35 medical centers and 454 medical offices. The system provides prepaid health plans that emphasize prevention and consolidated services designed to keep as many services as possible in one location (KP, 2010). Kaiser is also at the forefront of experimenting with reconceptualized roles for nurses that are improving quality, satisfying patients, and making a difference to the organization’s bottom line.
Nurses in San Diego have taken the lead in overseeing the process for patient discharge, making it more streamlined and efficient and much more effective. Discharge nurses now have full authority over the entire discharge process until home health nurses, including those in hospice and palliative care, step in to take over the patient’s care. They have created efficiencies relative to previous
8
Personal communication, Bruce H. Hamory, Executive Vice President and Chief Medical Officer Emeritus, Geisinger Health System, April 27, 2010.
9
Personal communication, Tine Hansen-Turton, CEO, National Nursing Centers Consortium, and Vice President, Public Health Management Corporation, August 11, 2010.
10
See https://members.kaiserpermanente.org/kpweb/aboutus.do.
11
Personal communication, Marilyn Chow, Vice President, Patient Care Services, Program Office, Kaiser Permanente, August 23, 2010.
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processes by using time-sensitive, prioritized lists of only those patients who are being discharged over the next 48 hours (instead of patients who are being discharged weeks into the future). Home health care nurses and discharge planners stay in close contact with one another on a daily basis to make quick decisions about patient needs, including the need for home health care visitation. In just 3 months, the number of patients who saw a home health care provider within 24 hours increased from 44 to 77 percent (Labor Management Partnership, 2010).
In 2003, Riverside Medical Center implemented the Riverside Proactive Health Management Program (RiPHM)™, an integrated, systematic approach to health care management that promotes prevention and wellness and coordinates interventions for patients with chronic conditions. The model strengthens the patient-centered medical home concept and identifies members of the health care team (HCT)—a multidisciplinary group whose staff is centrally directed and physically located in small units within the medical office building. The team serves panel management and comprehensive outreach and inreach functions to support primary care physicians and proactively manage the care of members with chronic conditions such as diabetes, hypertension, cardiovascular disease, asthma, osteoporosis, and depression. The expanded role of nurses as key members of the HCT is a major factor in RiPHM’s success. Primary care management nurse clinic RNs and licensed practical nurses (LPNs) provide health care coaching and education for patients to promote self-management of their chronic conditions through face-to-face education visits and telephone follow-up. Using evidence-based clinical guidelines, such as diabetes and hypertension treat-to-target algorithms, nurses play important roles in the promotion of changes in chronic conditions and lifestyles, coaching and counseling, self-monitoring and goal setting, depression screening, and the use of advanced technology such as interactive voice recognition for patient outreach.
Through this model of care, nurses and pharmacists have become skilled users of health information technology to strengthen the primary care–based, patient-centered medical home. Nurses use disease management registries to work with assigned primary care physicians, and review clinical information that addresses care gaps and evaluate treatment plans. RiPHM has provided a strong foundation for the patient-centered medical home. By implementing this program and expanding the role of nurses, Riverside has sustained continuous improvement in key quality indicators for patient care.
Guided care is a new model for chronic care that was recently introduced within the Kaiser system. Guided care is intended to provide, within a primary care setting, quality care to patients with complex needs and multiple chronic conditions. An RN, who assists three to four physicians, receives training in such areas as the use of an electronic health record (EHR), interviewing, and the particulars of health insurance coverage. RNs are also provided skills in managing chronic conditions, providing transitional care, and working with families and community organizations (Boult et al., 2008).
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The nurse providing guided care offers eight services: assessment; planning care; monitoring; coaching; chronic disease self-management; educating and supporting caregivers; coordinating transitions between providers and sites of care; and facilitating access to community services, such as Meals-on-Wheels, transportation services, and senior centers. Results of a pilot study comparing surveys of patients who received guided care and those who received usual care revealed improved quality of care and lower health care costs (according to insurance claims) for guided care patients (Boult et al., 2008).
Summary
The VA, Geisinger, and Kaiser Permanente are large integrated care systems that may be better positioned than others to invest in the coordination, education, and assessment provided by their nurses, but their results speak for themselves. If the United States is to achieve the necessary transformation of its health care system, the evidence points to the importance of relying on nurses in enhanced and reconceptualized roles. This does not necessarily mean that large regional corporations or vertically integrated care systems are the answer. It does mean that innovative, high-value solutions must be developed that are sustainable, easily adopted in other locations, and rapidly adaptable to different circumstances. A website on “Innovative Care Models” illustrates that many other solutions have been identified in other types of systems.12 As patients, employers, insurers, and governments become more aware of the benefits offered by nurses, they may also begin demanding that health care providers restructure their services around the contributions that a transformed nursing workforce can make. As discussed later in the chapter, the committee believes there will be numerous opportunities for nurses to help develop and implement care innovations and assume leadership roles in accountable care organizations and medical homes as a way of providing access to care for more Americans. As the next section describes, however, it will first be necessary to acknowledge the barriers that prevent nurses from practicing to the full extent of their education and training, as well as to generate the political will on the part of policy makers to remove these barriers.
BARRIERS TO TRANSFORMING PRACTICE
Nurses have great potential to lead innovative strategies to improve the health care system. As discussed in this section, however, a variety of historical, regulatory, and policy barriers have limited nurses’ ability to contribute to widespread transformation (Kimball and O’Neil, 2002). This is true of all RNs, including those practicing in acute care and public and community health settings, but is most notable for APRNs in primary care. Other barriers include
12
See http://www.innovativecaremodels.com/ and http://www.rwjf.org/reports/grr/057241.htm.
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ANNEX 3-1
STATE PRACTICE REGULATIONS FOR NURSE PRACTITIONERS
TABLE 3-A1 State-by-State Regulatory Requirements for Physician Involvement in Care Provided by Nurse Practitioners
State
Physician Involvement Requirement (for Prescription)
On-Site Oversight Requirement
Quantitative Requirements for Physician Chart Review
Maximum NP-to-Physician Ratio
Alabama
MD Collaboration Required
10% of the time
10% of all charts, all adverse outcomes
1 MD - 3 full-time NPs or max. total of 120 hours/week
Alaska
None
None
No
N/A
Arizona
None
None
No
N/A
Arkansas
MD Collaboration Required
None
No
None stated
California
MD Supervision Required
None
No
4 prescribing NPs - 1 MD
Colorado
None (although preceptor and mentoring period required for prescribing during the first 3,600 hours of prescriptive practice)
None
No
5 NPs - 1 MD; board may waive restriction
Connecticut
MD Collaboration Required
None
No
None stated
Delaware
MD Collaboration Required
None
No
None stated
Florida
MD Supervision Required
None
No
1 MD - no more than 4 offices in addition to MD’s primary practice location (If MD provides primary health care services)
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State
Physician Involvement Requirement (for Prescription)
On-Site Oversight Requirement
Quantitative Requirements for Physician Chart Review
Maximum NP-to-Physician Ratio
Georgia
MD Delegation Required
None
All controlled substance Rx w/in 3 mos of issuance of Rx, all adverse outcomes w/in 30 days of discovery, 10% of all other charts at least annually
4 NPs - 1 MD
Hawaii
MD Collaboration Required*
None
No
None stated
Idaho
None
None
No
N/A
Illinois
MD Delegation Required
At least once per month (no duration specified)
Yes, periodic review required for Rx orders
None stated
Indiana
MD Collaboration Required
None
Yes, at least 5% random sample of charts and medications prescribed for patients
None stated
Iowa
None
None
No
N/A
Kansas
MD Collaboration Required
None
No
None stated
Kentucky
MD Collaboration Required
None
No
None stated
Louisiana
MD Collaboration Required
None
No
None stated
Maine
None (although supervision by a physician or nurse practitioner is required for first 24 months of NP practice)
None
No
N/A
Maryland
MD Collaboration Required
None
Yes (percentage left to MD & NP discretion)
None stated
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State
Physician Involvement Requirement (for Prescription)
On-Site Oversight Requirement
Quantitative Requirements for Physician Chart Review
Maximum NP-to-Physician Ratio
Massachusetts
MD Supervision Required
None
Yes (for Rx only - once every 3 months, percentage left to MD & NP discretion)
None stated
Michigan
MD Delegation Required
None
No
None stated
Minnesota
MD Delegation Required
None
No
None stated
Mississippi
MD Collaboration Required
At least once every 3 months
Yes - a representative sample of either 10% or 20 charts, whichever is less, every month
None stated
Missouri
MD Delegation Required
NP must first practice for at least one month at same location of collaborating MD, after which time MD must be on-site once every 2 weeks
Yes - once every 2 weeks
3 FTE NPs - 1 MD
Montana
None
None
15 or 5% of charts, whichever is less, reviewed quarterly (may be reviewed by MD or NP peer)
None stated
Nebraska
MD Collaboration Required
None
No
None stated
Nevada
MD Collaboration Required
Part of a day, once a month
Yes (percentage left to MD & NP discretion)
3 NPs - 1 MD
New Hampshire
None
None
No
N/A
New Jersey
MD Collaboration Required
None
Yes - periodic review (percentage left to MD & NP discretion)
None stated
New Mexico
None
None
No
N/A
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State
Physician Involvement Requirement (for Prescription)
On-Site Oversight Requirement
Quantitative Requirements for Physician Chart Review
Maximum NP-to-Physician Ratio
New York
MD Collaboration Required
None
Yes at least once every 3 months (percentage left to MD & NP discretion)
4:1 NPs to physicians (only applies if more than 4 NPs practice off-site)
North Carolina
MD Supervision Required
None
Yes (for initial 6 months of collaboration, must be review and countersigning by MD w/in 7 days of NP-patient contact & meetings of NP-MD on weekly basis for first month, & then at least monthly for next 5 months)
None stated
North Dakota
MD Collaboration Required
None
No
None stated
Ohio
MD Collaboration Required
None
Yes - periodic review (annually, percentage left to MD & NP discretion)
3 NPs - 1 MD
Oklahoma
MD Supervision Required
None
No
2 FTE NPs or max
4 PT NPs - 1 MD
Oregon
None
None
No
N/A
Pennsylvania
MD Collaboration Required
None
Yes (percentage left to MD & NP discretion)
4 NPs - 1 MD
Rhode Island
MD Collaboration Required
None
No
None stated
South Carolina
MD Delegation Required
None
No
3 NPs - 1 MD
South Dakota
MD Collaboration Required
No less than one half day a week or 10% of the time
Yes (percentage left to MD & NP discretion)
4 NPs - 1 MD
Tennessee
MD Supervision Required
Once every 30 days (no duration specified)
20% of all charts every 30 days
None stated
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State
Physician Involvement Requirement (for Prescription)
On-Site Oversight Requirement
Quantitative Requirements for Physician Chart Review
Maximum NP-to-Physician Ratio
Texas
MD Delegation Required
For sites serving medically underserved populations: at least once every 10 days (no duration specified). 10% for designated alternative practice sites.
10% of all charts
3 NPs or FTE - 1 MD (for alternative practice sites, 4 - 1; can be waived up to 6 - 1)
Utah
MD Collaboration Required**
None
No
None stated
Vermont
MD Collaboration Required
None
Yes (percentage left to MD & NP discretion)
None stated
Virginia
MD Supervision Required
MD must “regularly practice” at location where
NP practices Yes - periodic review (percentage left to MD & NP discretion)
4 NPs - 1 MD
Washington
None
None
No
N/A
West Virginia
MD Collaboration Required
None
Periodic and joint review of Rx practice (no percentage specified)
None stated
Wisconsin
MD Collaboration Required
None
No
None stated
Wyoming
None
None
No
None stated
NOTES: For the purposes of this chart, “collaboration” includes all collaboration-like requirements (such as “collegial relationship,” etc.).
FTE = full-time equivalent; MD = medical doctor; NP = nurse practitioner; PT = part time; Rx = prescription.
* This requirement will be altered pending new rules in 2011.
** For controlled substance schedules II-III only.
SOURCE: NNCC, 2009. Reprinted with permission from Tine Hansen-Turton, NNCC. Copyright 2009 NNCC.
REFERENCE
NNCC. 2009. NNCC’s state-by-state guide to regulations regarding nurse practitioner and physician practice 2009. http://www.nncc.us/research/ContractingToolkit/contractingtoolkitgrid.pdf (accessed December 6, 2010).
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