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For APRNs, Innovation Trumps Barriers

 |  By Alexandra Wilson Pecci  
   July 16, 2013

Three healthcare institutions that rely on advanced practice registered nurses prove that a little innovation can go a long way in improving not only access to care, but also the care itself.

Advanced practice nurses are the most clutch players in the healthcare game, there to fill the gaps when primary care providers are in short supply. Three institutions show the innovative ways that APRNs can provide care, despite a number of significant hurdles.

A policy brief from the Robert Wood Johnson Foundation highlights three healthcare institutions where APRNs are being used effectively. It says the US Department of Veteran Affairs, the University of Pennsylvania Health System, and Duke University Health System's Department of Cardiovascular Medicine can serve as a model for other institutions who want to use APRNs in more pioneering ways.

The eight-page brief also identifies three of the most significant barriers to APRN's practice and touts statistics showing their effectiveness. In this regard, it's a lesson we already know: APRNs can help expand access to care; the types of APRNs; the licensing, training, certification, and education required of them; and stats about the way APRNs improve care.

The brief also outlines the three main barriers to APRNs' practice: legal/regulatory barriers (such as laws requiring APRNs to work with a collaborating physician and lack of reimbursement from government and private insurers); institutional barriers (restrictions from individual healthcare organizations); and cultural barriers (patients' notion that doctors provide better care).

But what I found the most interesting about this report were the three institutions that were spotlighted as APRN innovators.

The first profiled institution is the US Department of Veteran Affairs, which the brief says employs more than 5,000 APRNs "to deliver primary, specialty, acute, ambulatory, telehealth, and home healthcare services." The VA plans to implement a new, system-wide policy this year that will allow all APRNs who meet certain criteria to practice without direct physician supervision, even in states that don't allow it, using its federal status to override state laws, the brief says.

The policy aims to standardize rules across different VA facilities so that APRNs who work at several facilities won't encounter differing rules about the ways they can practice. The VA will also issue guidance about an expanded list of APRN core privileges including signing admission and discharge orders, making patient rounds, and preparing progress notes.

Another example highlighted in the brief is the Transitional Care Model (TCM) at the University of Pennsylvania Health System, which uses APRN specialists to develop and execute wide-ranging discharge plans. Trials of the effectiveness of the program in high-risk, high-cost, high-volume patients found that it resulted in everything from reduced costs for at-risk pregnancies and preterm infants to improved outcomes and satisfaction among chronically ill older adults. Experts say that use of the TCM in the broader healthcare system could have amazing results.

"If brought to scale, the TCM could accelerate efforts within the U.S. to move from a fragmented health care system to an integrated, high-performing one," Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology and director, NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, is quoted as saying in the brief.

Finally, the brief points to Duke University Health System's Department of Cardiovascular Medicine, which "leverages interprofessional teams to increase access to care and improve patient satisfaction." In other words, physicians and APRNs tag-team with patients, dividing duties between them.

Physicians develop care plans for new patients; NPs and PAs see returning or acutely ill patients; and RNs coordinate follow-up care, schedule procedures, and respond to triage calls. They also consult with each other as needed.

Such a model "requires a cultural shift," says Allison Dimsdale, DNP, RN, NP. But the effort to make the shift seems to be worth it: A pilot showed that patients like the model and that the average wait time for appointments dropped 57% for new patients and 75% for returning patients.

I found the examples in this brief heartening and exciting. Yes, there are things standing in the way of APRNs, but as these institutions show, a little innovation can go a long way in improving not only access to care, but also the care itself.

Alexandra Wilson Pecci is an editor for HealthLeaders.

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