Practice Elements of NP Admission
Over the past decade, RNAO and NPAO have consistently advocated for maximum integration and utilization of the nurse practitioner role throughout the health care system in order to achieve outcomes consistent with improved patient outcomes and government policy agendas. Both organizations actively participated in public consultations across Ontario regarding the role and scope of NP practice and provided submissions and feedback to the Social Policy Committee, Health Minister Caplan and the Health Professions Regulatory Advisory Council (HPRAC).
On April 8, 2011, the Ministry of Health and Long-Term Care (MOHLTC) proposed changes to Regulation 965 of the Public Hospitals Act, 1990, that provided nurse practitioners the authority to admit, treat and discharge hospital inpatients. According to the Ministry, these changes were proposed in order to provide Ontario's hospitals with a new health provider option for admission, treatment and discharge planning to optimize the use of health human resources and increase access to care while reducing wait times and improving delivery of patient-centred care.
RNAO and NPAO supported the MOHLTC’s proposed changes as enabling NPs to admit in-patients to hospitals will increase client access to health services, enhance continuity of care and caregiver, and reduce fragmentation of the client experience while improving patient flow through the system, thus reducing overall wait times. It is therefore in the best interest of Ontarians to enable NPs to admit in-patients to hospitals. Effective admission, treatment and discharge processes work best hand-in-glove as more admissions by NPs will contribute to hospital care effectiveness. Improvements in timely discharge and reductions in lengths of stay will serve to advance hospitals’ efficiency.
Streamlining care for the most effective and efficient use of health care resources requires us to conceive of admission as a process of providing care, and not a single act. Continuity of care provider is facilitated by the most appropriate care provider who admits patients from the ED. Frequently this may be the NP, who takes episodic brief histories and assessments in the ED and can then follow up with the same patients on the unit to which they are being transferred. Authorizing NPs to admit in this manner reduces duplication of assessments, decreases the potential for miscommunication and enables a more therapeutic and satisfying therapeutic relationship. Furthermore, the need for time-consuming and inefficient medical directives is eliminated
Overall, the key reasons to implement NP admission are:
- Enhanced coordination and continuity of health care provided outside the hospital setting (community, long-term care and primary health care settings) and within hospitals,
- Improved patient care and safety,
- Optimal utilization of NP competencies,
- Enhanced inter-professional collaboration, and
- More effective and efficient use of Ontario’s health care resources
Who Benefits from NP Admission?
Currently 30 per cent of NPs work in various acute care environments including emergency departments (ED). Extending NPs’ authority to admit-patients provides continuity of caregiver along with quality and safety improvements for patients in virtually all clinical areas.
Many patient populations benefit from NP admission. Given the demographic shift to an aging population, many patients require care for chronic disease management, and the senior population in particular, may derive very specific benefits from the continuity and coordination of care between community and hospital enabled by NPs having authority to admit, treat and discharge. NP admission is also needed for hospital-based NPs who work in both the ambulatory and in-patient settings. Enabling NPs to admit allows continuity of care and continuity of caregiver for any patient with acute and chronic disease diagnoses.
Impact of NP Admission on Human Resource Capacity, Geography and Access to Care
As indicated in NPAO’s September 1, 2010 submission to HFO, NPs in a variety of practice settings currently experience barriers to providing continuous, high-quality care due to the inability for NPs to admit. For community NPs, in particular, there are significant geographic differences. In teaching hospitals in Toronto as well as large community hospitals in the GTA, many family physicians do not have hospital admission or discharge privileges. If the patient of a community-based NP in these geographic areas requires hospitalization for any reason the admission process is normally through Emergency. Once in ED there are variable processes involving ED physicians / nurse practitioners and specialists. The decision to admit is currently made by the specialist referred to or the ED physician. However, in rural areas the role of the family physician may be very different where they as the primary care provider may have hospital admission and discharge privileges and care for their patients once in hospital. This may apply to acute care, transitional / rehabilitative care and complex continuing care units. This type of care model may also apply to select units within larger community hospitals for transitional care units, and rehabilitation units and possibly complex continuing care. There is a particular need to enable the NP to admit on units where primary care providers already admit, treat / provide care to, and discharge hospital patients. It is inefficient for the NP to require the physician to admit and discharge in these situations. In northern, remote and/or under-served communities, NPs having the authority to admit will ensure that patients do not experience delays in care due to the need to obtain a physician’s authorization to admit and may decrease the unnecessary use of Emergency Department services for admitting. A closer collaboration between the hospital and community care, and long-term care will be fostered by NPs having the authority to discharge and this will smooth this process and may lessen lengths of stay in hospital. In areas where few family doctors have hospital privileges, NPs having authority to admit, treat and discharge will help to ensure more effective chronic disease stabilization and coordination and continuity of care between community, hospital, and long-term care.
Evidence supporting NP Admission
Available data acknowledges the many benefits associated with increasing the utilization of NPs in terms of patient satisfaction, preventing unnecessary hospital admissions, decreasing length of stay and promoting early hospital discharge. However, there is a lack of quality Canadian research quantifying the cost-effectiveness of NP care. A cost analysis by Holland entitled “Economic evaluation of nurse practitioners versus GPs in treating common conditions” indicates that 19 million Euros per year could be realized by one NP. The capacity to influence care has also been seen in the role the NP play in development and dissemination in evidence based practices. This was seen by many team members as a key role; in particular, administrators and physicians found this to be an important role for NPs.
Health system outcomes are optimized when all regulated care providers are working to their full scope of practice. When hospitals implement NP admission they are maximizing NP’s contribution to the delivery of accessible, quality health care services to Ontarians. NPs are already exercising this authority safely in other jurisdictions (the UK, New Zealand, and Australia). By legislating and implementing NP admission, Ontario has become an innovator and lead Canadian jurisdiction in supporting NPs full integration within the health care system.
Lakeridge Health Whitby is the first NP Led Model of care maximizing full scope of practice for NPs. They are admitting, treating and discharging patients as the most responsible provider/practitioner (MRP) within an inter-professional team and have received provincial, national and international accolades.
NP Admission: Not an Act but a Process of Care
An important concept is to think of admission, treatment and discharge as processes of providing care rather than single acts as they may once have been years ago in much less complex health-care systems. Admission and discharge processes in hospitals are increasingly a focus for quality improvement and an area where the patient experience is continually being evaluated and improvements made based on continuous evaluation. Healthcare models where NPs practice on inter-professional teams are of greatest benefit to patients, hospitals, and the healthcare system. Collaboration with a team however needs to have capacity to enact the whole plan of care. Currently, the physician team member, who is least accessible, is the only one able to complete the entire plan. This gate keeping role is at odds with timely team based actions. Therefore any models that are developed require the NP to be an equal partner in a team with physicians and other professionals as indicated by the patients’ condition. Some Ontario examples of innovative models utilizing NPs to admit, treat and discharge include:
- Central East LHIN’s GAIN Geriatric Clinic (Geriatric Assessment and Intervention Network), which establishes the admission from urgent/ emergent clinics for seniors at four hospitals (Lakeridge, Rouge Valley, Scarborough & Peterborough) to ACE (Acute Care of the Elderly) in-patient units.
- NP-led C.A.R.E. model of Lakeridge Health where the NP is the MRP for complex continuing care patients.
- NP-led Transitional Care model of Parkwood Hospital where patients are transitioned from acute care to home effectively reducing ALC in acute care.
Practice Competencies Required for NP Admission
While NPs are accountable for adhering to the CNO’s standards of NP professional accountabilities and obligations, it should be noted that providing additional authority to any regulated health professional does not require all members of that profession to actually exercise their full authority. As self-regulating professionals, NPs use their knowledge, skills and judgment to exercise authorities within their area of practice based on their individual level of competency.
Furthermore, no credentials other than those indicated by the CNO for all NPs should be required. As self-regulating professionals, every NP is responsible for practicing in accordance with the standards of the profession, and for keeping current and competent throughout her or his nursing career. NPs in all areas would be expected to exercise their authority to admit, treat and discharge within their specialty and scope of practice.
The Accountability of “MRP”
It is important in the renewal of our healthcare system to move away from conceptual models that enable a single point of access to the system and towards team-based decisions of care. To facilitate this shift in thinking and corresponding policy, the term “Most Responsible Physician” is best termed “Most Responsible Provider” or “Most Responsible Practitioner” to reflect the authority that is now placed in providers other than physicians to admit and discharge.
Collaborative Practice Models
Inter-professional collaborative practice models are necessary to implement the changes required to enable NPs to exercise the authority to admit and discharge. Key features that should be included in such a model have been articulated in the NPAO Project “Development of an Accord on the Nurse Practitioner Role in Ontario: Developing Models of Interdisciplinary Practice that Enhance Patient Care (The Accord Project). Funded by the Primary Health Care Transition Fund (PHCTF) of the Ontario Ministry of Health and Long-Term Care, the project was proposed to be a vehicle for advancing a proactive, planned change process targeting the NP role within the Ontario health care system.
The Collaborative Practice Model should include:
- Attention to unmet patient needs within the current health care climate,
- Creation of high energy, team-based practices (therapeutic micro-cultures) that promote patient-centred care and inter-professional practice,
- An explicit and shared understanding of cultural assumptions held by professional disciplines,
- Role positioning of the NP role at leadership levels, and
- Application of existing research on NP outcomes and inter-professional role effectiveness.
NP Admission and Hospital Bylaws
There is variability in the existence of admission, treatment and discharge policies among hospitals and programs across Ontario. Where such policies have been established, they are usually outlined in by-laws and policies. When NPs are provided the authority to admit, individual hospital by-laws would require revisions to allow NPs to fully exercise this authority within the inter-professional team and the practice setting. The need for templates addresses key points for standardization across hospitals in Ontario, rather than individual practices that may not completely enable the full scope of practice for the NP.
Amendments to hospital by-laws and policies that would be critical to revise would include all those that would affect the authority or potentially create barriers to NP exercising full authority to admit/discharge. These would include, but are not limited to:
- Revising Privileged Staff by-laws;
- Including NPs in Most Responsible Provider (or Physician) policies;
- Replacing medical advisory committees (MACs) with Inter-professional Advisory Committees (IACs) and ensuring NP representation on the IACs;
- Amend the Schedule of Benefits for Physician Services to equitably recognize the NP as a direct referral source for which specialists can claim a deserved consultation fee.
In order to enact a smooth transition and effect the changes needed to provide NPs authority to admit, treat and discharge, hospitals must lead, embrace and manage the changes required throughout their organizations. While it is not difficult to enact changes to policy, gaps can exist between legislation, provincial policy directives and on-the-job practice. These gaps may occur when changes are not effectively communicated and/or practice settings are resistant to change. For example, even though midwives are primary health care providers with authority to admit and discharge in Ontario, a 2007 survey found that 48% of midwives experiences barriers
to their working to their full scope of practice.
Credentialing and privileging NPs for Admission
(Note: Hospital credentialing is not required for NPs employed by the hospital)
The goal of privileging is to:
- Assure high quality of patient care,
- Mitigate hospital and partnership risks,
- Provide a clear and standardized process to ensure consistency across the sites and corporation,
- Provide privileges that may expand based on evolving clinical mastery, advanced training, and increased services required,
- Supervise practice initially, expanding to a more autonomous level of performance as efficacy and safety is assured, and
- Link with the CNE and Lead NP/ NP Professional Practice Leader
The general process for hospital credentialing and privileging is as follows:
- Data is collated for the Credentialing Committee (regarding the NP’s proof of registration, certification, educational preparation, proof of malpractice insurance; proof of skill performance) and approved,
- The Privileging Committee grants privileges to the practitioner,
- The Medical Advisory Committee approves,
- The Hospital Board approves,
- A letter is sent to the NP from the CEO of the hospital, the Program Leader and the Physician Leader, which outlines the scope and limitation of the privileges granted.
NP Admission and Inter-professional Team
Data from the Specialty NP study indicates the NP informs physician practices by inclusion of specialized evidence, greater understanding of team roles and hospital processes. Therefore, having this knowledge available to a decisional body would provide a greater capacity for decisions that are not based on one professional perspective.
NP Admission and Fair Compensation
NPAO strongly supports that there should be one salary-based model, consistent with the current compensation model for NPs in hospital settings. There should also be sustained, dedicated funding for hospital-based NP positions. When NPs are funded largely from global hospital budgets this threatens their positions in times of fiscal change. Funding models that should be considered include salary and on-call stipends (if applicable). If on-call stipends are provided to other on-call health care staff, NPs should also receive this compensation. Team-based incentives are not seen as a fair and equitable way to foster inter-professional team collaboration or quality of care, according to a recent cochrane summary. Finally, all referrals to specialists, including those from NPs, should be compensated at the same rate.
NP Admission and Liability
NPAO does not believe that any additional liability insurance would be required when NPs gain authority to admit and discharge. Currently, most NPs in Ontario hold professional liability insurance obtained through the Canadian Nurses Protective Society, which automatically provides occurrence-based professional liability coverage to NPs in Ontario who are members of the RNAO and registered with the College of Nurses of Ontario (CNO) as an RN(EC). Under the Regulated Health Professions Statute Law Amendment Act, 2009 (Bill 179) all health professionals in Ontario will be required to hold professional liability insurance. In response to this requirement, CNO has introduced amendments to its General By-Laws (article 44.4) to require all members to hold Professional Liability Protection (PLP). This By-Law would come into effect only if and when the government proclaims new provisions in the Health Professions Procedural Code related to professional liability protection.
Implementing NP Admission
Every hospital will need to develop their own NP admission implementation plan. NPAO would welcome working with the Ontario Hospital Association and Chief Nursing Executives to develop a framework for implementing and evaluating the changes required to enable NPs to fully exercise the authority to admit and discharge.
Elements of the implementation framework should include:
- A comprehensive review and revision of related enabling legislation and hospital by-laws and policies. The aim of this should be to identify and eliminate barriers to NPs exercising the new authority and create consistency of practice and policy across the province.
- A communications plan to inform and promote “buyin” and collaboration from all professions that make up health care teams, thereby enabling all health care professionals (including respiratory therapists, occupational therapists, physiotherapists, etc.) to accept orders from NPs.
- Mechanisms for NPs to be registered as the Most Responsible Provider and contribute as such to the development of electronic heath record processes.
Utilizing NPs’ education, competencies and skills to full scope will improve patient access to hospital care and the hospitalization experience. It will undoubtedly result in improved patient, organizational and system outcomes, as well as advance robust inter-professional collaboration. We urge all Ontario hospitals to realize these varied benefits by maximizing NP utilization for admission, treatment and discharge.