CCMSD celebrates nurse practitioners

The president and regional director of the American Association of Nurse Practitioners (AANP) visited Crook County on Friday to tour a healthcare facility that's become known for its creative use of nurse practitioners (NPs).

Dr. April Kapu, president of the organization, spoke to a piece of legislation recently introduced in the U.S. House of Representatives that she said would remove a number of the administrative barriers between nurse practitioners and the care their patients need.

"This hospital – this community – has embraced the role of the nurse practitioner, and it thrives. We can see what NPs can do and what they can bring to the state," said Maria Kidner, Region 8 Director for AANP, explaining why she chose Crook County Memorial Hospital for Kapu's tour.

Kidner complimented Crook County Medical Services District (CCMSD) on having grown an "incredible facility" using nurse practitioners and said it shows that, "It can be done, and that we provide safe and high-quality care that's really patient-centered."

Kapu and Kidner believe CCMSD models a positive path forward for the role of the nurse practitioner.

"It's really nice to hear how well nurse practitioners are utilized here," said Kapu. "...We're very good at coordinating care and making sure patients are getting the right care."

Kidner, who was instrumental in developing the nurse practitioner role in remote critical care access in Wyoming, said that CCMSD's creative use of nurse practitioner care was the reason she chose this location as soon as she heard Kapu was coming to Wyoming.

As the first NP on the State Trauma Team in 2002 and one of the first in a cardiology specialty practice in Wyoming, she believes NPs have an important role to play in critical access care.

"In this state, this NP role is critical – we don't have enough physicians to reach our patients, and we need to be able to have the authority and the knowledge and the skills to do what we do in the middle of nowhere and be part of the community at the same time," she said.

ICAN Act

The "Improving Care and Access to Nursing", or ICAN, Act, H.R. 8812, intends to remove the barriers that prevent NPs from providing certain types of care. For example, it would allow them to to order and supervise pulmonary and cardiac rehab; certify when diabetic patients need therapeutic shoes; have their patients fully included in the attribution process for the Medicare Shared Savings Program; refer patients for medical nutrition therapy; certify a terminal illness for hospice eligibility; and perform mandatory examinations in skilled nursing facilities.

AANP is among a group of organizations supporting the bill, also including the American Association of Nurse Anesthesiology, the American College of Nurse-Midwives and the American Nurses Association.

The ICAN Act could have a strong impact on critical access facilities like the hospital in Sundance, said Wesley Davis, DNP. He spoke to the "conundrum" of the diabetic shoe to illustrate how administrative barriers throw a wrench in the works when it comes to the care an NP can provide.

"The crazy thing is that if you come in to the emergency department, I can cut your chest open, I can put in a chest tube, I can put in central lines, I can put in an airway – but I can't write a simple prescription for a pair of diabetic shoes," he said. "Those unnecessary roadblocks are ancient and antiquated."

Kidner agreed, speaking to her own experience.

"In cardiac rehab, I can do a maximum stress capacity study on someone with acute chest pain. [If you are] unstable, I can put you on a treadmill, watch you and supervise it and interpret it – but I cannot do that in cardiac rehab, where you're stable," she said.

Common Sense

Kapu explained the bill itself, which she said sews together pieces of legislation that have previously appeared in other, larger bills but did not go through. Most are "common sense" items, she said.

"They're documentation types of things that create big barriers for patients," said Kapu.

"...These are big access services and, when you have an administrative barrier, it can really slow down the patient getting the care they need."

One of those services is the aforementioned diabetic shoes. Right now, if an NP is working with a patient who has complex diabetes, they must advise them to make an appointment with a physician, who will certify for the shoes and will be listed as the attending for that care.

That sounds fine, said Kapu, but it's not necessarily a speedy process in a rural area.

"Another big component of the bill is that NPs would be able to order cardiac and pulmonary rehab and supervise," Kapu said. Legislation in 2018 made it possible for NPs to supervise such rehab but, said Kapu, "It's the ordering piece that's so vital."

Kapu herself works in acute care and works with cardiac and thoracic patients and says here, too, time can be of the essence.

"Just about all my patients need cardiac or pulmonary rehab – one or the other – when they leave. I fortunately work in a hospital so I can find someone to help me with that order, but essentially...this gets them to it faster," she said.

NPs meanwhile provide a lot of the day-to-day care in many skilled nursing facilities.

"Currently, they are not able to do the admitting examination so the patient can be admitted there, which is really important," she said. "Most of the time they are there and able to do the intake."

This particular provision, agreed CCMSD staff, is a big one for Crook County and will be extremely beneficial if the bill is passed.

"As you can see, this is a big deal. It's pulling those vital things down and saying, look, we need to get this care to these patients right away – we can do that. We're qualified, we're educated, we're trained, we're board certified to provide this exact type of care," said Kapu.

Full Practice

The ICAN Act is intended to address the barriers associated with the Centers for Medicare and Medicaid Services (CMS), which impose restrictions at the federal level. It does not change how individual states permit NPs to practice.

Many states have already passed legislation that demonstrates they have no issue with NPs performing the functions addressed in the ICAN Act. Wyoming, for example, is among the 26 states – as well as Washington, D.C. and two territories – to be full-practice.

This means that state practice and licensure laws allow NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments. According to AANP, this is the model recommended by the National Academy of Medicine and National Council of State Boards of Nursing.

"In the pandemic, because of the executive orders and so forth, most states had executive orders where they relieved some of these restrictions. It was a wonderful time to step up and continue to show what we do," Kapu said. "Four states went ahead and moved over to full-practice – Massachussets, Delaware, Kansas and New York."

It's so far proven to be a positive step, she continued. In terms of states that have moved to full-practice authority, she said, "We've actually seen an increase in collaboration, in communication, in coordinating care, as well as improved outcomes, increased workforce etc."

Recognition

As the gathering reached its end, Mayor Paul Brooks signed a proclamation recognizing U.S. Nurse Practitioner Week on November 13-19 after sharing his experience of growing up in a small town that was 80 miles from the nearest hospital with a nurse for a mother.

Back before restrictions on such things were tightened, he said, his mother would call the doctor in the city, then treat patients at the dining room table. He commented that the ICAN Act seems like a good move back in the right direction.