Transcript Presentation_APRN_Role_byLW - Coalition for Nurses in Advanced

APRN Practice & Professional Advocacy
in Texas
Lynda Woolbert, MS, RN, CPNP-PC, FAANP
APRN Consultant & CNAP CEO
1
Overview
APRN Consensus Model & LACE (Module I: Unit 1)
• APRN Practice in Texas, Scope of Practice & Licensure
•
(Module I: Units 1 & 2)
Prescriptive Authority (Module I: Unit 2)
• Texas Legislative & Regulatory Process (Module II)
• Advocating Effectively (Module II)
• Scope of Practice Review & BON Disciplinary Issues
•
(Module I)
•
CNAP & Texas Nurse PAC (Module II)
Notes in “normal view” contain further explanation &
information you may need to know for testing.
2
Why study APRN practice legislation &
regulation now?
• Must adhere to the law from the first day you
practice as an APRN
• Evaluate & learn throughout clinical experiences
• Know resources to stay current
• Avoid being featured on 10 o’clock news as two
NPs were for dispensing controlled substances to
treat obesity. (Harwin Weight Loss Clinic News Clip)
3
Consensus Model
for APRN Regulation
aligns
Licensure, Accreditation,
Certification and Education
(LACE)
4
APRN Consensus Model: LACE
Accreditation Organizations
Educational Programs
Certification Organizations
Boards of Nursing
(BON is the state agency that licenses APRNs to protect the
public.)
5
Consensus Model for APRN Regulation:
Licensure
6 POPULATION FOCUS AREAS (Population Foci)
Family
(Lifespan)
Adult
Gerontology
Acute or Primary
Nurse
Anesthetist
CRNA
NurseMidwife
CNM
Neonatal
Pediatrics
Acute or
Primary
4 APRN
ROLES
Women’s
Health
(Gender Related)
Clinical
Nurse
Specialist
CNS
&
Psychiatric
Mental
Health
Nurse
Practitioner
CNP*
6
Licensing Titles
CRNA
CNM
CNS
NP
AGCNS
AGNP
ACAGNP
FCNS
FNP
NCNS
NNP
PCNS
PNP
ACPNP
PMHCNS
PMHNP
WHCNS
WHNP
7
Scope of Practice (SOP)
• Professional SOP – based on:
– APRN education;
– Certification; and
– SOP statements by professional organizations.
• Personal (Individual) SOP – based on personal
competency.
• State SOP – based on occupational licensing
laws in the state.
8
Elements Determining Scope of Practice (SOP)
*Education
*Certification
Competency
• SOP is not determined by:
Pre-NP specialization as an RN; or
Setting.
• While an employer may limit SOP, an employer can
never expand SOP beyond that legally permitted.
Source: NONPF. (2012). Statement on acute care and primary care certified nurse
practitioner practice.
9
Scope of Practice References
• BON Guidelines for Determining Scope of
Practice with FAQs on Scope of Practice
www.bon.texas.gov/practice_scope_of_practice_aprn.asp
Professional organizations representing the APRN role and
population focus. Examples
– AANP: scope and standards applicable to all NPs
– AACN: scope and standards applicable to acute care NPs
– NAPNAP: scope of practice for pediatric nursing from RN
through primary care and acute care PNPs.
10
Review
What is the difference between
certification organizations;
professional organizations; and
licensing boards?
Know the purpose of each, how they differ from
each other, and the interests they represent.
11
Statutory and Regulatory Basis
of
APRN Practice in Texas
12
Statutory – Laws passed by the
state legislature (Nursing Practice Act)
Regulatory – Rules passed by
state agencies based on
authority granted by the state
legislature (BON Rules)
13
?
What is the state’s purpose in
regulating health
professionals?
14
Consensus Model for APRN Regulation
Role & population determine licensure.
BONs do not regulate specialization.
POPULATION FOCUS AREAS (FOCI)
Family
or Individual
(Lifespan)
Adult
Gerontology
Neonatal
Pediatrics
Women’s
Health
Psychiatric
(Gender Related)
Mental
Health
APRN ROLES
Nurse
Anesthetist
CRNA
NurseMidwife
CNM
Clinical
Nurse
Specialist
CNS
Nurse
Practitioner
(Acute or Primary)
CNP*
15
Advanced Practice Titles in Texas
BON Rule 221.2
Nurse Anesthetists (CRNAs)
Nurse-Midwives (CNMs)
Nurse Practitioners (NPs)
Clinical Nurse Specialists (CNSs)
NCSBN. (2014). APRNs in the U.S. https://www.ncsbn.org/170.htm
16
BON Rules & Regulations for APRNs
§ 219 APRN Education
§ 221 APRN Licensure and Practice
(expect revisions in 2017-2018)
§ 222 Prescriptive Authority
(new rules adopted November 15, 2013)
http://www.bon.texas.gov/laws_and_rules_ru
les_and_regulations.asp
17
Population Foci Titles
• Nurse Practitioners
•
•
•
•
•
•
•
•
•
•
•
BON Rule 221.2 & BON Policy
Acute Care Adult
Clinical Nurse Specialists
Acute Care Adult/Gero
Adult Health / MS
Acute Care Pediatric
Adult/Gerontology
Adult
Adult/Gerontology
Community Health Nursing
Family
Critical Care Nursing
Gerontological
Gerontological Nursing
Neonatal
Pediatric
Pediatric Nursing
Psychiatric/Mental Health
Psychiatric/Mental Health
Women’s Health
Nursing
Advanced Practice Titles in Texas
BON Rule 221.2
• Current Rule - Advanced Practice
Registered Nurse (APRN) is umbrella term
and not a title to use after your name.
• NPA was amended in 2013, and BON issues
APRN licenses.
• When BON revises rules in Chapter 221,
BON will propose licensure and titling
consistent with the Consensus Model.
19
BON Rules & Regulations for APRNs
§ 219 APRN Education
§ 221 APRN Licensure and Practice
§ 222 Prescriptive Authority
REMEMBER…
All BON Rules apply to APRN practice.
20
All BON Rules Apply to APRNs
Particularly Note:
Chapter 217
§ 217.11 Standards of Nursing Practice
§ 217.12 Unprofessional Conduct
§ 217.14 Registered Nurses Performing
Radiologic Procedures
§ 217.18 RNs that First Assist at Surgery
21
First Assisting at Surgery
• §217.18 requires RNs that first assist:
– Complete a RNFA program (listed on CCI Website,
www.cc-institute.org/crnfa/certification/steps/programs).
– CNOR certified; or
APRN licensed - Limits RNFA scope to APRN
Population Focus.
22
ALL BON Rules Apply to APRNs
In addition to Chapter 217, Note:
Chapters 216, 224, and 228
Chapter 216 – Continuing Competency
Chapter 224 – Delegation to unlicensed personnel
in acute care setting
Chapter 228 – Pain Management
Rules BON identifies as particularly relevant to APRNs are listed
on the Advanced Practice Information webpage.
23
Other BON Resources
• Position Statements
• Texas Board of Nursing Bulletin
• APRN Practice webpage
http://www.bon.texas.gov/practice_nursing_practice_aprninfo.asp
24
BON Rules require RNs follow all state &
federal rules that apply to their practices.
Examples:
Texas Medical Board (TMB)
Texas State Board of Pharmacy (TSBP)
Texas Health & Human Services Commission
(HHSC)
Federal - Center for Medicare & Medicaid Services
(CMS)
25
APRN Licensure & Renewal
BON Rules – Chapter 221
26
APRN Licensure in Texas
•
•
•
•
•
BON Rule 221.4
2nd license in addition to RN license
APRN license – AP######
Verify APRN license on BON website
New application required for each role
and/or population focus
Requirements
– New graduate and national certification; or
– 400 hours practice and current national
certification
27
New Graduate APRN License (BON Rule 221.4)
with Prescriptive Authority (BON Rule 222.2)
1. Complete & submit licensure and Rx Authority
applications (online preferred);
2. Submit additional documents;
3. Pass a certification exam recognized by the
BON; and
4. Notify BON
5. Receive APRN License & verify Rx Authority
Number online.
28
Remember
Until BON notification or verification on BON
website of full APRN licensure,
• Do not use APRN skills except under direct
supervision; and
• Do not use or claim an APRN title (including
Graduate FNP, etc.)
29
Remember
Do not sign a prescription until:
• Prescriptive authority number is verified on BON
website, and
• Physician delegates prescriptive authority &
signs Prescriptive Authority Agreement (PAA) or
Facility-Based Protocols (as applicable to the
type of practice).
30
Interim Approval
(Not an option for new graduates and no interim
approval is consistent with Consensus Model)
BON Rule 221.6
• Short term approval until all documents
received and reviewed.
• Up to 120 days, no extensions
• Interim approval granted only 1 time per
APRN role & population focus area
• No prescriptive authority
31
Applicants for Texas APRN License
Currently Licensed in Other States
• Must have unencumbered Texas RN license or be
a resident of a RN Licensure Compact state with
a privilege to practice in other Compact states
• No interstate APRN Compact option - must
complete the full application process for
Licensure and Prescriptive Authority
• BON expected to eliminate option for Interim
Approval in 2017-2018.
32
Maintaining APRN Licensure
BON Rules 216.3 & 221.8
• Renew APRN license in conjunction with RN
license attesting requirements were met.
– Current national certification in the role &
population focus area;
– 400 hours of current practice;
– 2 hours jurisprudence/ethics CE in past 6 years;
– 2 hours of CE in caring for older adults; and
– APRNs with Rx authority must have 5 hours of
pharmacotherapeutics CE within the past 2 years .
Those with Rx authority for controlled substances
(CSs), need an additional 3 hours related to CSs. 33
How to Sign Your Name (current rules)
• “RN” identifies licensure
• Identify APRN role & population focus, e.g.
FNP, ACNP, CNM, ACNS
• Multiple APRN role / population foci -- use
the title that applies.
Lynda Woolbert, RN, PNP
Lynda Woolbert, MS, RN, CPNP-PC, FAANP
34
Likely Signature Requirements in 2018
• RN or APRN could identify licensure.
• Identify APRN role & population focus, e.g.
FNP, ACAGNP, AGNP
• Multiple APRN role / population foci -- use
the title that applies.
Lynda Woolbert, APRN, PNP
Lynda Woolbert, MS, APRN, CPNP-PC
In accordance with current statute but not BON rules
35
APRN Practice:
Autonomous vs. Delegated
Elements of APRN
Scope of Practice in Texas
36
Delegation
• Transferring authority from one person to
another
• Delegation always implies supervision
• Ordering a service to be provided by a licensed
individual is NOT delegation.
• Physicians have broad delegatory authority.
• RNs and APRNs have limited delegatory
authority based on BON Rules in Chapters 224
and 225.
37
APRN Practice: What is Autonomous?
• Assessments
– Histories & physical exams
– Ordering diagnostic exams
– Interpreting diagnostic tests
• Recommending OTC Drugs
• Establishing treatment plans in the APRN’s
scope of practice (excludes Rx & other functions
specifically requiring physician delegation)
• Referrals, Consultation, Coordination of Care
38
Texas APRN Practice: What is Delegated?
• Based on definition of Professional Nursing in
the NPA & no exclusion for APRNs.
– Medical diagnosis; and
– Prescribing & ordering drugs, medical devices and
durable medical equipment are delegated.
• Based on Provisions in Other Texas Laws
– Signing medical verifications for disabled parking
placards
– Ordering Orthotics and Prosthetics
• Medicaid Rules can Limit Scope of Practice
39
Medical Aspects of Care
BON Rule 221.13 (d)
Medical Aspects of Care are acts that require
physician delegation through a written
document. Either a:
• Prescriptive Authority Agreement (PAA); or
• In facility-based practice, Protocols or other
written authorizations (standing medical orders,
standing delegation orders, or other order or protocol)
40
What are the physician’s liability
implications for delegated acts?
• Except when subject to other provisions in the law
and/or mitigating circumstances, the delegating
professional is liable.
•
•
The Medical Practice Act (statute) and TMB Rule 193.5
include a partial exemption for physicians delegating
prescriptive authority.
TMB Rule 193.5(b) states: “…delegating physicians remain
responsible to the Board and to their patients for acts
performed under the physician's delegated authority.”
41
When performing medical aspects
of care, is the APRN practicing
medicine or nursing?
• All health care professionals have overlapping scopes
of practice.
• Professional practice acts recognize this by including
a provision exempting other health professionals.
• When a nurse performs “medical acts,” the nurse is
practicing NURSING.
42
Overlapping Scopes of Practice
NP · PA · MD · DO
Pharmacists
Therapists
Dentists
Optometrists
Radiology Techs, etc….
All health professionals have SOPs that overlap in
some way.
43
Facts about Physician Assistants (PAs)
• Regulated by the Physician Assistant Board
• Licensing Statute is in Medical Practice Act (Subtitle B,
Chapter 204, Texas Occupations Code).
• PA rules are in Chapter 185 of the TMB Rules.
• Education is similar to 3rd year medical school.
• Scope of practice is based on supervising physician.
• All aspects of PA practice are delegated by the
supervising physician.
• In Texas, PA & APRN prescriptive authority are identical.
44
Collective Terms for APRNs & PAs
• Best to call professionals by their names, e.g.,
Nurse Practitioner
Physician Assistant
• When a collective term is used:
Avoid mid-level provider or practitioner
Exception: DEA
Better: Advanced Practice Providers (APP)
or advanced practice practitioners.
45
Prescriptive Authority
in Texas
Nursing Statute (NPA): §§301.152 & 301.168
BON Rules: Chapter 222
Medical Statute (MPA): §§157. 051 – 157. 060
TMB Rules: 193.5 – 193.14 and
Applicable Definitions in TMB Rule 193.2
46
Definitions
Prescribing vs. Ordering
• Prescribing
– Prescription filled at outpatient pharmacy
– Must have prescriptive authority to sign a Rx
– Includes orders written in long-term care facilities
• Ordering
– Medications dispensed from inpatient pharmacy for
administration
– Must be consistent with facility policy and “Protocol,
PAA or other written authorization”
47
Definitions
Two Broad Drug Categories in Texas Law
 Dangerous Drugs - Drugs & medical devices that
require a prescription, excluding controlled substances.
 Controlled Substances (with limitations) –
Drugs deemed to have abuse potential and subject to
additional regulation. Controlled substances are divided
into 5 schedules.
48
Controlled Substances (CSs)
• Schedules are based on abuse potential & medical use.
I - highest abuse with no medical use
II - high abuse with recognized medical use
III - moderate abuse potential
IV - moderate to low abuse potential
V - some abuse potential
www.deadiversion.usdoj.gov/schedules/#define
• Schedules III-V are subject to less regulation than
Schedules I and II.
www.deadiversion.usdoj.gov/schedules/
49
A Universal Limitation on APRN
Prescriptive Authority
Scope of Practice
In any state, prescriptions are
limited to the scope of practice
authorized by state law and the
state’s board of nursing.
50
Limitations on APRN Rx Authority
in Texas
• Delegated & Supervised
• No Schedule II Controlled
Substances in most practices
51
Rx Authority Delegation
• MD or DO licensed in Texas
• Witten delegation document:
– Protocol if facility-based; or
– Prescriptive Authority Agreement (PAA).
• Physicians register APRNs & PAs to whom they
delegate Rx authority through a PAA.
• Physician & APRN must keep records until 2 years
from the date the PAA is terminated.
Resources:
CNAP’s Sample Prescriptive Authority Agreement
CNAP’s Sample Facility-Based Protocols
A Guide for APRN Practice in Texas
FAQs on TMB and BON Websites
52
MD may delegate ordering & prescribing:
 Dangerous Drugs – Any category
 Controlled Substances (CS)- Limitations
• Schedules III – V
• 90-day Rx (or refills equal 90-day supply)
• Prior authorization required for:
–Refills beyond 90-days
–Any CS for Children Under 2 yrs.
• Schedule II to APRNs treating:
– patients in hospital ER (APRN must be facility-based)
– Inpatients (APRN must be facility-based); or
– Hospice patients
53
Rx Authority Review
An APRN from a nurse licensure compact state is
going to practice in Texas for four months. What
licenses must the APRN have before prescribing
dangerous drugs in Texas? (Check all that apply)
a) Texas RN license
b) Texas APRN license
c) Texas APRN prescriptive authority number
d) DEA Controlled Substances Registration
54
Texas Prescriptive Authority Law
Special Practice Designations
exempt from certain restrictions
• Do not submit site changes to BNE or the
Texas Medical Board (TMB)
55
Prescriptive Authority
Two Types of Practice Designations
• Practice serving a medically underserved
population
• Facility-based practice or site
56
Medically Underserved
• Medically Underserved Population (MUP) Definition
– Federally designated HPSA, RHC, FQHC
– Public health or family planning clinic under contract with
HHSC or DSHS
– Designated by DSHS (Health Professions Resource Center)
http://www.dshs.texas.gov/chs/hprc/presauth.shtm
– Titles V, X, XVIII, XIX, XXI Federal funding or state-funded
– County, state or federal correctional facility
– Any practice designation as a site serving a MUP prior to
March 1, 2013.
57
Medically Underserved
• PAA requirements same as other sites
• Advantage - No physician to APRN/PA ratio
• Physician limited to delegating at no more
than 3 MUP practices = 150 hrs./wk.
58
Facility-Based Sites
• Licensed Hospital
– Only delegated by certain physicians
– Limited to 1 hospital (under facilitybased hospital provisions)
• Long-term Care Facility
– Only delegated by medical director
– Limited to 2 facilities
59
Facility-Based Sites: Advantages
• Licensed Hospital
– No delegation ratio
– May use protocols or PAA
• Long-term Care Facility
– 1 physician to 7 APRN/PA ratio (no advantage)
– May use protocols or PAA
• Physicians delegating under facility-based
provisions may delegate to 7 additional
APRNs/PAs through a PAA.
60
Protocols
BON Rule 221.13 (d)
• Preferred written delegation document in
facility-based practices
• Protocol should promote the exercise of
professional judgment commensurate with:
– APRN’s education and experience; and
– Complexity of patient’s condition.
• Advantage – No specific QAI requirements
that are specified in the PAA.
61
Prescriptive Authority Agreement (PAA)
• Written document through which a physician
delegates the authority to order and prescribe drugs
and/or devices in all practices except facility-based.
• Remains an option for facility-based.
62
Requirements for Parties to the PAA
• Physicians are limited to delegating Rx authority
to no more than 7 APRNs and/or PAs (FTEs)
• All parties must disclose:
– Prior disciplinary action by the licensing board before
executing the PAA.
– Investigation by the licensing board while a party to the PAA.
• All parties must cooperate with TMB and BON staff
during an inspection or audit relating to the PAA and its
implementation.
63
PAA Requirements
•
•
•
•
•
In writing, signed and dated by all parties
Name, address & professional license # of parties
Nature of the practice, locations, or settings
Categories of drugs that may or may not be prescribed
Plans for:
–
–
–
–
Consultation & referral
Addressing patient emergencies
Communicating & sharing information related to treatment
Quality assurance and improvement (QAI) that includes chart
review, meetings, & documenting implementation of QAI
64
QAI Plan Requirements
• Chart review - Number determined jointly
• Purpose/content of QAI monthly meetings
– share information about patient care & treatment,
– changes in treatment plans and
– issues relating to referrals
• QAI monthly in-person meetings
– Location, day and time determined jointly
– Face-to-face 1 year for APRNs who prescribed for 5 of past 7 yrs
– Face-to-face for 3 years for APRNs with less experience
• Thereafter, meet quarterly in-person & monthly in
between by electronic means.
• Document implementation method & compliance
65
?
Would a NP be able to
prescribe dangerous drugs or
medical devises without a DEA
registration?
66
Prescribing Standards
67
Prescribing Standards:
Writing a Prescription
• Avoid abbreviations on The Joint
Commission’s “Do Not Use” list
• Refer to Stewart & DeNisco or The
Joint Commission
https://www.jointcommission.org/facts_about_do_
not_use_list/
68
Prescription Form
1.
patient's name and address;
2. name, strength, and quantity of the
dangerous drug or controlled substance;
3. directions to the patient regarding taking the
drug and the dosage;
4. intended use of the drug, if appropriate;
5. name, address, and telephone number of the
delegating physician;
continued
69
Prescription Form – cont’d
6. APRN’s prescriptive authority #
7. address & telephone # of site;
8. date of issuance;
9. number of refills permitted; and
10. If a controlled substance:
– DEA # for APRN & MD/DO
– DEA # for APRN
BON Rule 222.4(b) & TSBP Rule 291.34 (b)(7)(A)
70
Prescribing Standards: Generic Substitution
• Requires written and faxed prescriptions
designate “brand medically necessary” or
“brand necessary” in the prescriber’s
handwriting.
• Rules allow electronic prescriptions if
“brand necessary” is designated on the
prescription.
TSBP Rule 309.3
71
BON 222.4 Prescribing Standards
• Off label use permitted only if:
– Part of a research protocol approved by IRB or
Expanded Access authorized clinical trial
– Within the current standard of care and
supported by evidence-based research
• Patient-practitioner relationship must exist
– Do not prescribe for self, friends or family
• May treat STDs for partners of established
patient after examining the patient
72
Prescribing Controlled Substances (CSs)
Follow limitations and requirements for prescribing
controlled substances limitations specified in BON Rule 222.8
1. Schedules 3-5 only if do not meet requirements in #4
2. 90-day Rx (or refills equal 90-day supply)
3. Prior authorization required for:
– Refills beyond 90-days
– Any CS for Children Under 2 yrs.
4. Schedule 2 to APRNs treating:
– Patients in hospital ER (APRN must be facility-based)
– Inpatients (APRN must be facility-based); or
– Hospice patients
5. Obtain a DEA # before prescribing any CS.
73
Prescribing Standards: Controlled Substances
• Schedule 3 - 5 Controlled Substances (CSs) may be:
–
–
–
–
prescribed on a standard prescription form;
prescribed electronically;
called to the pharmacy by a practitioner or designated agent; and
refilled up to 5 times within 6 months of Rx issuance.
• Essential Resources if prescribing CSs
–
–
–
–
–
BON Prescribing Controlled Substances Rule, 22 TAC §222.8
Pain Management Rules – BON Chapter 228 & TMB Chapter 170
TSBP CS Rules – Chapter 315
TSBP – Resources on Abuse & Misuse (including TMB links)
DEA Practitioner’s Manual
74
DEA Controlled Substances (CSs) Registration
1. Must have delegated prescriptive authority for CSs.
2. Apply for DEA# online - Form 224
www.deadiversion.usdoj.gov/drugreg/index.html
3. Include address of the primary practice where you will be
prescribing CSs.
4. Business activity. APRNs mark “MLP – Nurse Practitioner”.
5. Ensure the CSs schedules you mark are consistent with
those delegated in Protocols or PAA and with Texas law.
– Schedules 2 and 3 are subdivided into Narcotic and Non-narcotic
drugs. 2N and 3N signify the non-narcotic drugs in Schedules 2&3.
75
“Official Prescription Form”
• Term for the form required when prescribing Schedule II
Controlled Substances (CSs). (Also called triplicate)
• Schedule II CSs may be prescribed electronically.
• Practitioners signing the form must have DEA
registration that includes Schedule II narcotic &/or nonnarcotic drugs.
• Delegating physician must sign the APRN’s order form
for official prescription forms.
• If a physician terminates Schedule II Rx authority, the
APRN must return unused forms to the TSBP.
• Prescriptions for Schedule II drugs may not be refilled.
76
“Official Prescription Forms”
Schedule II Prescriptions must be:
•
•
•
•
Written for no more than a 30-day supply;
Filled within 21 days;
Printed in ink or typewritten; and
Dated for the day they are signed by the practitioner.
Prescriptions may never be:
• Postdated, or
• Pre-signed by a physician or other practitioner.
77
“Official Prescription Forms”
Schedule II Prescriptions may be:
• Prepared by a designated individual for signature
by the practitioner.
Multiple prescriptions:
• May be issued for up to a 90- day supply
• Other than the first prescription, must indicate the
earliest date on which a pharmacy may fill each
prescription.
78
What APRNs Must Know about Rx Authority
1. Apply for a prescriptive authority number when
applying for license to practice as an APRN.
2. Separate Prescriptive Authority required for each
APRN role & population-focus area
3. May not write prescriptions until a physician 1)
delegates authority, 2) signs PAA or Protocol
4. Register delegation on TMB website within 30 days.
5. May not prescribe controlled substances until have
DEA #.
6. May not prescribe for yourself, friends or family. 79
?
What Texas state agencies regulate the
information included on a prescription form
when the APRN signs a prescription for a
controlled substance? (Check all that apply.)
a) Board of Nursing (BON)
b) Department of Public Safety (DPS)
c) Texas Medical Board (TMB)
d) Texas State Board of Pharmacy (TSBP)
80
Advocacy
and the
Texas Legislative Process
81
Barriers to Practice
• Federal Level
– Some Medicare reimbursement policies
– APRNs not allowed to order home health in
Medicare & Medicaid
• State Level
– Definition of Professional Nursing in the NPA
– Physician delegation
– Limitations on controlled substances
– Provisions in the Insurance Code
– Some Medicaid reimbursement policies
82
Texas Legislative Basics
• Begins with Interim Charges.
• Stakeholders take part in hearings.
• Session starts the 2nd Tuesday in January.
• Bills are filed by legislators until 60th day.
• Companion bills – Same bill filed in House & Senate
• The same bill number must pass House & Senate
• The Regular Session lasts 140 days
• Governor may call a 30-day Special Session for
specific purpose/s (The Call)
83
Texas Legislative Session Cycle
2016
• Interim Charges issued fall 2015 – 1/16
• Elections – 3/1, 5/24, 11/1
2018
• Interim Reports – 11/1 – 12/1
• Begin Pre-filing bills 85th Legislature
• 85th Session Begins 1/10
2017 • Bill filing deadline 3/11
• Session Ends 5/29
Special
Session
2017
• Governor calls
• Special Purpose – “The Call”
• 30-day
Legislative Process: Bill to Statute
•
•
•
•
•
•
•
•
Bill Introduced & Referred to Committee
Committee Hearing → Committee Report
Floor Vote → Engrossed
Received in 2nd Chamber & Referred
Committee Hearing → Committee Report
Floor Vote → Enrolled
Sent to Governor → Signed
Statute (Law)
85
Legislation to Regulation
86
Legislation
• Texas Legislature
passes a bill.
• Governor signs into
law.
• Statute directs state
agency to
implement.
Regulation
• State agency proposes
& adopts rules
• Agency takes action
within statutory
authority against
regulated persons /
entities that violate
rules.
87
Advocacy Basics
• What is the difference between legislation and
regulation?
• Does the Texas Legislature meet in Regular
Session every year?
• Does your congressman work in Austin or in
Washington, D.C.?
• How do you address your state legislators?
• How do you find your legislators’ names? Who
represents you in Austin & D.C.?
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Following Bills through Legislative Process
How to Find and Read a Bill
http://cnaptexas.com/texas-legislation
Finding a Bill www.capitol.state.tx.us
Legislative Process – Citizen Handbook & other
publications
http://www.lrl.state.tx.us/genInfo/LegProcess.cfm
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APRN Legislative Priorities in 2015
Remove unnecessary restrictions that prevent & delay care.
• Contract directly with insurance providers and serve as primary care
providers whether the delegating physician is in-network or not.
• Authorize physicians to delegate prescribing Schedule II medications
(especially to psychiatric APRNs and APRNs providing palliative care).
Handouts: http://www.texasnp.org/?84LegSession
2015 Legislative Summary
http://www.texasnurses.org/?page=SessionUpdates#ID
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APRN Legislative Priority in 2017
Full Practice Authority
But unlikely to pursue expansion of prescribing
Schedule 2 medications
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Visits with Legislators
• Lobbying is education – Identify purpose & 3 goals
• Flow of the visit
– Getting to know you – finding commonalities
– Listen before telling. Find out what the legislator /staff
knows about your issue/s.
www.house.state.tx.us for info on representatives
www.senate.state.tx.us for into on senators
– Give the information the legislator needs.
– End on time with your request.
• Follow-up with a letter to the legislator & staff.
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Visiting/Writing Legislators
• Research the issue & ask for help as needed.
APRN state & national organizations and Policy
Institutes: www.texaspolicy.com & www.cppp.org
• Address the right issue to the right legislator
• Limit to 1 page
– Use enclosures as necessary
• Use correct forms of address
– “The Honorable Donald Doorman” to address the envelop
– “Dear Representative Doorman:” to open the letter
• Include your card / your contact information.
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Writing Legislators by Email
• Be sure the email will be read by asking if email is a
preferred form of communication.
• Write it like a letter - Include a salutation & closing
• Edit very carefully
• Remember how easily emails are forwarded
• Never put anything in an email you would not
want the public to read.
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Relationships with Legislators
• Be a regular
– At least 3 - 4 contacts a year
– Meet with legislators in home district
– Always be polite, even when you disagree
• Visit when you need no favors
• Write notes – Handwritten notes are good
– Congratulatory
– Items or articles of interest
• Volunteer and donate
• Attend fundraisers
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Responding to Action Alerts
•
•
•
•
•
•
•
•
Read the entire alert carefully. Clarify if needed.
Verify the alert is from a reputable source.
Respond if appropriate in time frame requested.
Read & Follow directions/guidelines exactly.
Put your response in your own words.
Edit carefully.
Close the loop. Let requestor know you responded.
Responding through an organization’s automated
response system
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Becoming an Effective Advocate
• Join and attend professional meetings
• Get informed & organized
–
–
–
–
Register or Join to receive professional org.’s updates
Organize so everyone plays to their strengths
Recruit colleagues
Do what you can, when you can
• Join your statewide professional organizations
TNA, TNP, and CNAP.
• Contribute to Texas Nurse PAC
• Form relationships with your legislators & staff.
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NP Week at the Capitol
Sponsored by TNP
November 6 – 12, 2016
APRN Legislative Day
Sponsored by APRN Alliance
February 2017
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Reasons the BON Disciplines APRNs
Scope of Practice Review
What To Do If a Complaint is Filed
BON Disciplinary Options
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Administrative Violations of the NPA
• Fails to:
– Obtain APRN Licensure
– Renew APRN Licensure
– Renew RN License
– Maintain National Certification
– Attain or maintain records of CE
– Sign name properly identifying APRN role & population
– Solicit / inform patients ethically or in accordance with
HIPPA
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APRNs Practice Violations
• Fail to:
– Maintain or annually sign /date Rx authority
written documentation
– Document
– Assess or monitor
– Maintain a safe environment for patient
– Refer to a physician or others
– Prescribe and/or administer drug
appropriately
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Mistakes Resulting in Serious Outcomes
• APRN Practicing as RN without proper
orientation
– Practicing as APRN in primary care does not
maintain high tech RN skills.
• Practicing when fatigued / over 12 hours
or too many days in a row.
(See the Texas BON Bulletin, April 2015.)
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Mistakes Resulting in Serious Outcomes
• Violating APRN Scope of Practice
most common cause for:
– disciplinary action R/T practice error;
and
– bad outcomes
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May APRNs provide any service or
perform any procedure delegated by a
physician?
NO
Must fall within formal APRN education:
• Population of patients
• Type of services
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Scope of Practice Review
Is a primary care educated NP permitted
to practice in a specialty?
YES
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Scope of Practice Review
Is a primary care educated NP
permitted to practice in a hospital?
YES,
But limited to the level of care included in
APRN educational program.
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What to do if a Complaint is Filed
•
•
•
•
Notice means BON opened an investigation.
You have 20 days to respond. Use the time wisely.
Identity of complainant is confidential.
Fail to respond, the case moves forward without
your side of the story.
• Consult an attorney and colleagues.
• If you have prescriptive authority through a PAA,
notify delegating physician and other parties.
Resources: BON Website & A Guide for APRN Practice in Texas, Chapter 9.107
BON Disciplinary Process: Chapter 213
Disciplinary Options
The BON may issue a Board Order taking any of the
following actions against the RN/APRN license:
• Warning (can be deferred)
• Reprimand
• Restrict
• Suspend
• Revoke
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BON Disciplinary Options
SB 1415 (2009) & SB 1058 (2013)
• “Corrective Action”
– BON finds nurse committed a minor violation of
the Nursing Practice Act or BON Rule.
– A non-disciplinary, administrative action.
– May count as a disciplinary action in future
sanctions
• Not reported to National Data Bank
• Not disclosed to public
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Corrective Action
• Determined by BON Executive Director
• First offense for:
– Delinquent license less than 6 months
– Noncompliance with CE
– Inaccurate answers R/T criminal history, etc.
– Fails to report new name or address to BON
– Fails to assure credentials for personnel
– Does not maintain peer review plan
• Fine is $500
Rules 211.7 & 213.32 adopted on 11-6-09
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BON Disciplinary Options
• Deferred Disciplinary Action
– Cases are eligible if a warning or lesser discipline
proposed (not a license reprimand, suspension or
revocation).
– If nurse completes requirements, BON removes
public record of the infraction after 5 years.
– May count as a disciplinary action in future sanctions
• Reported to National Data Bank but modified five
years after completing.
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More about the
Coalition for Nurses in
Advanced Practice (CNAP),
Texas Nurses Association, &
Texas Nurse PAC
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CNAP Mission
1. Educate APRNs and stakeholders about
the legal aspects of APRN practice;
2. Educate APRNs about advocating for
their practices; and
3. Promote regulations that allow APRNs
to reach their full potential to improve
the health and well-being of all Texans.
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CNAP APRN Group Members
CTCNM
Consortium
of Texas
Certified
NurseMidwives
Tx
Tx
Texas
Texas
ANNP
CNS
NAPNAP
PAPNs
Texas
Clinical
Nurse
Specialists
Greater
Texas,
Houston
Area &
South
Texas
Chapters
of the
National
Association
of Pediatric
NPs
Psychiatric
Advanced
Practice
Nurses :
Austin
San Antonio
Texas
Association of
Neonatal
Nurse
Practitioners
VANPs
Victoria Area
Nurse
Practitioners
TNA is taking a lead role in coordinating
the APRN legislative agenda through its
Advanced Practice Nursing Advisory
Committee, the Texas Team and the
APRN Alliance.
http://www.texasnurses.org/?page=TxTeam
Texas Nurse Practitioners (TNP) takes the
lead in advocating for legislative change
for NPs. TNP is also part of the APRN
Alliance. www.texasnp.org
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Texas Nurse PAC
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PAC – Political Action Committee
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PACs contribute money to support
political candidates
Incorporated organizations may not
make political contributions
Texas Nurse PAC
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Texas RN PAC became RN/APRN PAC in 1995
Administered by TNA, CNAP and TANA
Became the Texas Nurse PAC in 2015
Contributes to candidates for state office
When I give $$ to the Texas
RN/APRN PAC,
am I giving to a professional
group that hires lobbyists?
NO
PACs must be separate from prof.
organizations, e.g., TNA, TNP & CNAP
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Do Your Fair Share
Contribute $30 /mo. for
professional organizations
$15 /month to Texas Nurse PAC
( Total = 1 hour of your salary / month)
Visit your legislators 7 times
Spread the word and recruit 4
colleagues to do the same 120
Thanks for Joining CNAP
Questions?
Contact
Lynda Woolbert
[email protected]
(979) 345-5974
(512) 750-3747
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