Advanced Practice Nursing

Bundle Payments and health care expenditures - answer-- Also known as bundle payments - Reimburstment of health care providers on the basis of expected cost for clinically defined episodes of care - "middle" ground between fee-for-service and capitation - healthcare delivery system takes on financial risk of patient - Forces system to enhance quality and coordination of care - Incentivizes system to deliver care that truly meets the Triple Aim CHIP - answer-- Children's Health Insurance Program - Health coverage to uninsured children whose families earn too much to qualify for Mediciad but too little to afford private coverage Role Strain - answer-Subjective feelings of frustration, tension, or anxiety expierenced in response to role stress & can be feelings of decreased self-esteem when performance is below expectations Role Conflict - answer-Role expectations are percieved to be mutually exclusive or contraditctory Medicare Part D Billing - answer-- Prescription drug coverage - Must join a drug place to receive coverage under part D - Coverage is attempt to lower prescription costs - Payment is monthly fee that varies by plan & is addition to Part B premium or inbedded in Part C premium Role Stress - answer-A situation of increased role performance demand (ex: returning to school while maintaining work and family responsibilities or the expectation of increased workload Medicare Part B Billing - answer-- Covers medical expenses such as physician and outpatient care - Direct reimbursement can only occur when submitting claim through part B - Covers physician and nonphysical provider services, outpatient hospital services, home health care not covered by part A (PT/OT) and other services such as diagnostic testing, durable medical equipment and ambulance costs - Enrollment in part B is voluntary to those receiving Part A - Payment into system via monthly premiums that are established yearly based on system expenses through deductibles & coinsurance programs Advanced Practice Nurse Roles - answer-1. Nurse Practitioner 2. Clinical Nurse Specialist 3. Certified Registered Nurse Anesthetist 4. Certified Nurse Midwife Nurse Practition - answer-- provide care through diagnosis and treatment as well as addressing disease prevention and health management - 1893 Lillian Wald & Henry Street Settlement (HSS) House - HHS nurses obtained standing orders for emergency medications and treatments - nurses considered "good enough" to care for the poor whereas physicians seen as only careing for those who could pay - FNS/FSA nurse practice centered around the practice autonomy in the requirement that the patients be poor, marginalized and have little access to physician provided medical care - NP role formally described in 1960s and was implemented in outpatient pediatric clinics in response to a shortage of primary care physicians - Loretta Ford in 1965 established first Pediatric NP program (PNP) & was designed to prepare professional nurses to provide comprehensive well-child care and manage common childhood health problems - 1970 continue to enhance visibility in health system, and expand role while demonstrating cost effective quality care - role expanded/included because nurse role was essential to providing equal access to health care for all Americans - conflict surrounds role between other RN and NP and NP and physicians - issues surrounding prescriptive treatment & idaho in 1971 was first state to recognize diagnosis and treatment as part of practice - Support DNP but does not require educational programs to be at the doctoral level Clinical Nurse Specialist - answer-- evolved out of increasingly complexity of nursing care - roots in psychiatric nursing - psych specialists date back to 1880 & richards is credited with founding specialty of psych nursing specialists - Rutgers University first educational program for CNS but was for psychiatric nursing - coronary care nurse specialists established in 1962 & CCU nurses blurred invisible boundary separating nursing and medicine - 1960s noted to be when clincal nurse specialist took on modern day form - three social forces drove specialization 1. increase in specialty related information 2. new tech advances 3. response to public need and interests - crtical care and oncology specialty grew in 1970s - ANA recognized CNS role 1970s defining the CNS as an expert practitioner and change agent - master degree required - role has postive effect on improving nursing care and patient outcomes - view shift from direct patient care to education and organizations (seen as too valuable) - education complex due to number of specialties involved - can prescribe without physician supervision in 20 states now - 1997 Balanced Budget Act identified CNS eligible for Medicare reimburstment Certified Registered Nurse Anesthetist - answer-- history in civil war - typically anesthesia given only when a physician was unavailable - Dr Mayo first to recognize and formally train CRNA in 1889 -Alice Macaw mother of anesthesia (hired by mayo) - early challenges but practice has grown - 1931 Lakeside hospital establishes National Association of Nurse Anesthetists - LA medical association dues Nelson in 1934 for practicing without a license & nelson won but in response Chalmers-Frances filed another suit and judgement was the result only to have CA Supreme Court rule in favor of Nelson again and the practice of nurse anesthisa was legal/in scope as long as it was done under guidance of supervision of physician - reimburstment not clear cut - mandatory certification - master level education - after 2022 must have a doctoral degree Certified Nurse Midwife - answer-- history from start of time - isolated communities rely on midwives - "granny midwives" - Fontier Nursing Service (FNS) in 1925 & was decentralized network of nurse run clinics in rural mountains of kentucky - earliest school was the School of the Association for the Promotion and Standardization of Midwifery in 1932 - combination of two disciplines nursing and midwifery - issues with insurance coverage in 1980s because of complex delivery outcomes - 1990s higher demand and expansion in scope of practice - hospitals tried to limit profession and 1980s CNMs work under civilian health and medical program of the uniformed Services for military and were first to recieve reimbursements - 1984 recognized by all states in laws and regulations - can get certification or master degree - no evidence to support doctoral degree and DNP not required Nurse Educator Role - answer-- Responsible for designing, evaluating, updating, and implementing new and current nursing education curriculum - advisers and role models Nurse Administrator Role - answer-- Supervise nurses and other health care team members - recruit, hire, and train nurses Role Acquisition - answer-- Anticipatory socialization to APRN roles that occurs in graduate education - role rehersal - development of clinical knowledge and skills - creation of supportive network Medicare part A Billing - answer-- Covers hospital expenses - Does NOT reimburs the ARPN directly because those services are already paid for as part of the hospital expense - Includes inpatient care recieved in hospital or skilled nursing facility - Covers critical access hospitals, short-term care in skilled nursing facility, post institutional home health care and hospice care - funded through payroll taxes & beneficiary cost sharing (deductibles and coinsurance) ICD-10-CM codes - answer-- Documentation for billing a service - APRN use - Diagnosis for which services are provided is what these codes represent - forms basis as to why a service is being provided - this is the most current version (international classification of diseases 10th revision) - longer the code the more specific the information is about the diagnosis - Basis for why a service is provided & lists 69,000 ways a human body has disease, sign, symptoms, ect - All categories are 3 Characters - Subcategories are 4 or 5 characters - Codes can be 3, 4, 5, 6, 7 characters - Codes may start with a letter to signify disease followed by numbers that signify etiology, anatomic site and severity - ex: S32.01A is code for wedge compression fracture of first lumbar vertebra and initial encounrter for closed fracture Six sections for CPT codes - answer-- Actual service being provided - also documentation for billings services - specific services performed in relation to diagnosis - medical code, 5 digit number used to indicate level of service - six sections of codes: 1. evaluation and management 2. anesthesia 3. surgery 4. radiology 5. pathology and laboratory 6. medicine CPT codes by the APRN for initial hospital visits - answer- - Evaluation and Management (E/M) codes - must consider history, physical exmainiation, and medical decision making when deciding on what E/M code to use - Common CPT codes for outpatient: New patient CPT codes and establlished patient cpt codes - Common CPT codes for inpatient: Initial hospital visit CPT code , subsequent hospital visit CPT code and critical care CPT code 99291-99292 Intrapreneurship Acticities - answer-- when leaders use the enterpreneurial skills of innovation and risk taking and assume responsibility for achieving specific targets in an organization they are entrepreneurship - generally an employee in an exisiting health care system in which many of the indirect processes of the care delivery system may be controlled and managed by other Employees or departments - function within an institutional health care system aka microcosm of larger arena - risk taker - improves, redesigns or augments an employers current direct care process with a lesser role in day to day business administrative functions - dicrect clinical practice, guidance and coaching, leadership, and consultation - development of nurse triage and telemedicine services - transition care - development of interdisciplicary care teams - CRNA managed anesthesia provider services - Nurse triage problems - use of informatics to develop and implement new models of care delivery - development of nursing care policies Core foundation of all APRN education curricula - answer-1. Pathophysiology 2. Health and physical assessment 3. Pharmacology Entrepreneurship Activities - answer-- plans, organizes, finances, operatres and participates in new health care delivery organization - control over and responsibility for - function within the context of the larger, societal health care system - risk taker - leaders go outside of traditional employment systems to create new opportunities to exercise their unique abilities - direct clinical practice, guidance and coaching, leadership, and consultation - nurse owned primary care clinics, specialty ambulatory practice, birth center - interdisciplinary health care business ventures - APRN owned health care practices - development of new models of reimburstment for nursing care delivery - wound care - health navigation - chronic disease management - APRN staffing businesses - Nurse midwifery consultants TIGER competencies for APN role - answer-- bring together nursing stokeholds to develop a shared vision, strategies, and specific actions for improving nusing practice, education, and delivery of patient care through HIT (health information technology) - includes basic computer competencies, information literacy and information management - Technology Informatics Guiding Education Reform (TIGER) - competencies applied to all nurses - Basic Computer competency: gaining comfort and skill with actual hardware and software & includes personal computer management, smart phone management, manipulating software application, familiar with social media and using internet - Information Literacy Competency: information litereacy is crucial to incoporate evidence based practice into nursing practice & nurse must be able to determine that info is needed to assess outcomes of care, identify practice variation and establish best practice & also need critical thinking and assessment skills - Information management competency: underlying concept for performance measurement & includes collecting data, processing data, and presenting and communicating processed data and meaningful info or knowledge ICD or SNOMED CT Codes documentation - answer-SNOMED: organized collection of medical concepts that are essential for documenting clinical concepts such as problem lists and patient histories - Sytematized nomenclature of medicine clinical terms - assessment and outcome terms ICD: codes are alphanumereic designations given to almost every diagnosis, description or symptoms, and cause of death attributed to humans and used worldwide - used for documentation and billing of diagnosis and procedures as well as documenting cause of mortality from death certificates - international classification of diseases, 10th edition Moral Distress - answer-- Belief that they know the ethically appropriate action but feel constrained from carrying out that action because of institutional obstacles - experience of being seriously compromised as a moral agent in praciticing in accordance with accepted professional values and standards Concepts related to Moral Distress - answer-- Moral uncertainty: experience unease and question right course of action - Moral Dilemma: when obligations require or appear to require that a person adpot two alternative actions but the person cannot carry out all the required alternatives HIPAA - answer-Health Insurance Portability and Accountability Act - Law in 1996 - minimum patient privacy standards - goal to protect the privacy of patient identifiable health information & includes any information that would identify the patient, patient problems, plan of care, and how they are paid for - provide for how and when patient protected health information (PHI) may be used and under what circumstances it must be de-identified Health Professional Shortage - answer-- HSPA is an area in which there are more than 3500 individuals for every primary care physician - does not include availability of NPs or PAs - responsible for designating areas to be medically underserved areas and medically underserved populations - federal government established critera to desginate health professional shortage areas (HPSA) - use these designations to provide additional resources - lack of data on NPs is barrier to accuratly assess and plan for workforce needs -questions about validity of using general measures such provider to population ratio Need for DNP - answer-- prepared to sythesize exisiting research findings essential for EBP, to use data from sophisticated databases linked to EMR systems and national databases, and to participate in the formation of policies and procedures on facility wide or health system wide basis - original research - clinical consultant - design and participate in quality improvement projects - form strategic and productive alliances 2005 Donabedian Model - answer-- usede to evaluate quality of APRN care - Three quality dimensions 1. structure 2. process 3. outcomes - structure is care delivery context and factors that dictate how providers and patients behave (setting in which care occurs) - process is action taken in the delivery of health care (what is actually done in giving and receiving care) - outcome is the effect of health care on patients and populations (effects of care on the health status of patients and populations) - model is core of all other outcome measurments and role impact models - variables can be studied independently or as a model for overall APRN practice - Nursing role effectiveness model is based on this concept APRN Practice Model - answer-- Consensus model? - Hamric Integrative Model of Advanced Practice Nursing - conceptual definition of APN and define characteristics that include primary critera (graduate education, certification in specialty, focus on Clinical practice with patients) and a set of core competencies (direct clinical practice, collaboration, guidance and coaching, evidence based practice, ethical decision making, consultation, and leadership) - key components: primary critera, seven advanced competencies with direct care as the core, and environmental and contextual factors that must be managed for APN to florish - generic features of APN: 1. use of knowledge in practice 2. critical thinking and analytic skills 3. clinical judgement and decision making 4. professional leadership and clinical inquiry 5. coaching and mentoring 6. research skills 7. changing practice - three sphere of influence aka literature review on CNS practice to further support Hamric theory - first sphere (management of complex or vulnerable populations) three Characteristics of expert direct care, coordination of care and collaboration identified as essential & Second sphere: (educationing and supporting interdisciplinary staff) education, consultation and collaboration are important &third sphere (influence) facilitating innovation and change US Health System - answer-- information rich enviroment - health encounters occur for the exchange of information - in constant state of evolution - US does not provide universal coverage - Medicare - Medicaid - ACA - healthcare law goes through congress - Department of Health and Human Services (HHS) responsible for public health - Licensure, accreditation, certification, education occur through system Florence Nightengale - answer-- founder/mother of modern nursing - promote policy change to improve quality, dignity and equity for Crimean War - importance of using evidence to inform policy - work demonstrated how health policy faces challenges and opportunities in both big "P" and small "p" policies Policy - answer-- law, regulation, procedure, administrative action, incentive, or voluntary practice of government and other institutions - health policy is authoritative decisions pertaining to health or healthcare made in all branches of government that are intended to direct or influence the actions, behaviors, or decisions of citizens Benner's Seven Domains of Expert Nursing Practice - answer-- from novice to expert - based on expert practice of clinical nurses - domains are a combination of roles, functions, and competencies - domains not completely differentiated so there is overlap - domains: 1. helping role 2. administering and monitoring therapeutic interventions and regiments 3. effective management of rapidly changing situations 4. diagnostic and monitoring function 5. teaching and coaching funtion 6. monitoring and ensuring quality of health care practices 7. organizational and work role copetencies - is a conceptual model of practice Models of Conceptual Practice - answer-- set of relatively abstrat and general concepts that address the central insterest to a discipline, the propositions that broadly describe these concepts, and the propositions that state relatively abstract and general relations between two or more concepts - framework that tells how to observe and interpret the phenomenon of interest to the discipline and provides alternative ways to view the subject matter of the discipline - Hamric Integrative Model of Advanced Practicing Nurse: defined primary criteria for graduate education, certification in specialty, and a focus on clinical practice and a set of core competencies including direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, and leadership - Fenton/Brykcxynski: used Benner model, verified that nurses in advanced practice were experts showing more expertise than experience alone & both identified more domains and competencies & B identified 8th domain of the management of health and illness in ambulatory care settings - *Fenton, Benner & Brykcsynski model consists of the following: Benner identified these domains 1. Diagnostic/patient monitoring function 2. Administering/monitoring theraputic interventions and regulations 3. monitoring/ensuring the quality of health care practices 4. organizational and work role competencies 5. helping role of the nurse 6. teaching/coaching function 7. effective management of rapidly changing situation & Feton identified CNS domain of 8. the consulting role of the nurse & Bry. Identified NP domain of management of patient health/illness status in ambulatory care settings that falls under the first two domains of Benner. see drawn diagram* - Calkin Model helped nurse administrators to differentiate advance practice nursing from other levels of clinical pr Ruling of Supreme Court as result of Chalmers-Frances - answer-- 1936 Frances filed suit against Nelson resulting in judgement for Nelson - 1938 Nelson appealed the case to CA Supreme Court and it was ruled in facor of Nelson - Court established legal precedent that the practice of nurse anesthesia was legal and within scope of nursing practice as long as it was done under the guidance of a supervising physician Accountable Care Organizations (ACOs) - answer-- organizations or structures that assume responsibilities for a defined population of patients across a continuum of care, held accountable through payments linked to value, reliable performance measurements demonstrate savings are achieved with imporvements in care - key feature under reform of ACA -