KIMBERLY ENGLISH MSN, RN, FNP

Introducing Mid-level Practitioners into a Sleep Practice

Objectives n  Describe what is a mid-level practitioner

n  Discuss requirements of mid-level practitioners

n  Explain the role of mid-level practitioners

n  Discuss billing and reimbursement

What is a Mid-level Practitioner

n  Nurse Practitioner (NP, APRN)

n  Physician Assistant (PA)

n  Licensed Professional Counselor (LPC)

History

n NP/PAs 1960s

n Balanced Budget Act of 1997

Nurse Practitioner

n  Master prepared or Doctorate prepared nurse n  Certification Exam

n  Texas Board of Nursing

n  Prescriptive Authority n  Dangerous drugs n  Controlled substances

APRN n  Nurse Anesthetist (CRNA) n  Nurse-Midwife n  Nurse Practitioner

n  ACNP n  FNP n  PNP

n  Clinical Nurse Specialist n  Adult Health/Medical Surgical Nursing n  Critical Care Nursing n  Gerontological Nursing n  Pediatric Nursing n  Psychiatric/Mental Health Nursing

Physician Assistant

n  Master prepared n  National Certification Exam

n  Texas Medical Board

n  Prescriptive Authority n  Dangerous Drugs n  Controlled substances

LPC n  Master Education Counseling and Human

Development

n  Cognitive Behavioral Therapy (CBT) n  CBT Insomnia

n  Does not need practice agreement

n  Does not prescribe medications or DME

NP/PA

n  Practice Agreement/Collaborative Agreement n  delegates prescriptive authority

n  Quality Assurance

n  Texas Medical Board registration

Prescriptions

n Medications n Dangerous drugs n Controlled substances

n Durable medical equipment

New DME Requirements

n  DME face to face requirements n  Physician certify that NP, PA, CNS has performed face

to face within 6 months of prescribing DME n  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-

Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html

n  Rep. Jim McDermott (D-WA) =legislation, H.R. 3833, which would allow NPs/PAs to certify that the required face-to-face assessment with their patient has occurred when ordering DME products; no other provider would need to be involved.

DME Requirements

n  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html5.2.3.2.3 – Detailed Written Order for Covered Items

n  http://www.aanp.org/component/content/article/136-press-room/2013-press-releases/1390-update-regarding-cms-dme-face-to-face-rule-delay <http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html

Sleep Medicine Training

n  Schools

n  Programs

n  Textbooks

n  Orientation n  On the job training

Literature Review Quality of Patient Care by Nurse Practitioners and

Physician's Assistants: A Ten-Year Perspective. HAROLD C. SOX JR., M.D.

Ann Intern Med. 1979;91(3):459-468. doi:10.7326/0003-4819-91-3-459

Mundinger et al (2000). Primary care outcomes on patients treated

by nurse practitioners or physicians. JAMA, 283 Venning (2000). Randomised controlled trial comparing cost

effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal, 320

Literature Review

A randomised controlled crossover trial of nurse practitioner

versus doctor led outpatient care in a bronchiectasis clinic Thorax 2002;57:661-666 doi:10.1136/thorax.57.8.661

Bryant & Graham (2002). Advanced practice nurses: A study of client satisfaction. Journal of the American Academy of Nurse Practitioners, 14(2).

Business Models

n  Parallel

n  Sequential

n  Shared

n  Collaborative

Business Model

n  Parallel Model n  NP/PA stable patients n  Physician complex patients

Business Model

n  Sequential Model n  NP/PA initial visit n  Physician responsible for differential diagnosis and

management. n  Reverse would be physician seeing and then

assigning less complex patients to NP/PA

Business Model

n  Shared Model n  Seeing patients on an alternating schedule

Business Model

n  Collaboration Model n  Elements

n Autonomy n Competence n Collegiality n Communication n Trust

Benefits

•  Cost effective care

•  Coverage five days a week

•  Decreased wait time for appt

Constraints

•  Lack of public awareness of role

•  Lack of physician awareness of role

•  Territorialism of physicians

Clinic Role

n  Initial evaluations

n  New Consultations

n  Follow up

Billing/Reimbursement NP/PA

n  Provider number n  85% Medicare and Private Payors n  92% Medicaid

n  Physician provider number n  “Incident to “ billing

Billing/Reimbursement LPC

n  Own provider number

n  Mental health codes

n  Individual therapy hours

$$$$$$$$$$$$$$

n  Average office visits 200-300 per month

n  Variations of reimbursement: n  Type of visit n  Level of service n  Vacations/days off

Summary

Introduction of a Mid-level Practitioner to a Sleep Clinic would facilitate:

n positive patient outcomes n patient satisfaction n  staff satisfaction

?Questions?