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Pediatric Health and Advanced Practice: Past, Present, and Future

San Francisco Bay Area Chapter NAPNAP Fall Conference

November 8, 2014

Raji Koppolu, RN, MS, CPNP Pediatric Surgery

Lucile Packard Children’s Hospital Stanford

Objectives

S  1) Historical background to advance practice pediatric nursing and NAPNAP

S  2) Current trends in pediatric healthcare and implications for advanced practice

S  3) Future of pediatric healthcare with respect to workforce and discuss tools for effective leadership in practice

Where it all started…

S  http://www.youtube.com/watch?v=YNMki0i88xA

I attribute my success to this. I never gave or took any excuse. –Florence Nightingale

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A little history

S  1965: Dr. Loretta Ford and Dr. Henry Silver develop the first nurse practitioner program at the University of Colorado

S  1967: Boston College initiates one of the earlier master’s programs for NP’s

S  1973: More than 65 NP program exist in the U.S. The National Association of Pediatric Nurse Practitioners (NAPNAP) is established.

S  1978: The Association of Faculties and Pediatric Nurse Practitioners (AFPNP) is established

S  1979: Approximately 15,000 NP’s in the U.S.

1960’s 1970’s

Moving forward…

S  1983: 22-24,000 NP’s in the U.S.

S  1985: American Academy of Nurse Practitioners established

S  1994: Mundinger publishes “Advanced Practice Nursing-Good Medicine for Physicians” in the New England Journal of Medicine, further supporting facts that NP’s are cost-effective and quality primary health care providers

1990’s 1980’s

Most recently…

S  2001: 82,000 NP’s in the U.S.

S  2004: National Nurse Practitioner Week, held annual in November, is recognized in a proclamation by U.S. Congress

S  2014: More than 192,000 NP’s in the U.S.

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National Association of Pediatric Nurse Practitioners

www.napnap.org

www.sfnapnap.org

•  Mission: To empower pediatric nurse practitioners (PNPs) and their healthcare partners to enhance child and family health through practice, leadership, advocacy, education and research.

•  Core Values: Commitment, Leadership, and Integrity

NAPNAP, 2014

 

NAPNAP Strategic Mission

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Membership Update

60006500700075008000

7,800

11% growth over the past six years

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Current Trends In Pediatric Healthcare

Current Trends in Pediatric Healthcare

S  1) The clinical, social, and cultural demographic mix of patients and families is increasing

S  2) Increased advanced in information technology applied to the practice of healthcare and pediatrics

S  3) Advances in medical knowledge, technology, diagnostics, and treatment

S  4) The Healthcare delivery system will change and evolve

http://www2.aap.org/visionofpeds/megatrends_scenarios.cfm

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Current Trends in Pediatric Healthcare

S  5) There will be an increase in the consumer-driven nature of society and healthcare

S  6) There are needs for both specialists and primary care providers in order to make the healthcare home model work in the absence of a sufficient supply of providers

S  7) There will be increased economic, nutritional, and environmental threats to the health of the world’s children

S  8) Globalism will increasingly affect children’s health

http://www2.aap.org/visionofpeds/megatrends_scenarios.cfm

#1: Clinical, Social, Cultural & Demographic Mix

More and more children have long-term chronic health issues:

S  The percentage of U.S. children and adolescents with a chronic health condition has increased from 1.8% in the 1960’s to more than 7% in 2004.

S  5-year survival rates for childhood cancers have improved significantly

S  There are now more adult patients with congenital heart disease than pediatric patients

S  Mean survival for patients with cystic fibrosis has increased from 20 to mid 30’s

S  Complex medical, behavioral, and cognitive needs

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What we are learning…

S  Current approaches to asthma education do not address the vast range of information needs of parents

S  A few studies explicitly identify parental information needs in a comprehensive manner

S  Science review discovered four areas of parental information: asthma basics, treatment modalities, coping and medical expectations

Archibald, M.M & Scott, Shannon (2012). The information needs of North American parents of children with asthma: a state-of-the-science review of the literature. Journal of Pediatric Healthcare, 28, 1, 5-13.e2.

http://www.childtrends.org/databank/indicators-by-topic-area/

Source 1: Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. Accessed 11/1/2012. Source 2: The Centers for Disease Control and Prevention, National Vital Statistics Reports. Births: Final Data for 2010, Vol. 61 No. 01, August 2012. Accessed 11/1/12.

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Clinical, Social, Cultural Demographic Mix

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What can we do?

S  Increased caregiver involvement

S  Role of cultural effectiveness in working with diverse groups of patients and families

S  Value healthcare homes, educate communities, focus on vulnerable populations (children with special needs, prenatal care, transition to adult, mental health)

Access to Care

S  U.S. Population is more diverse facing barriers to healthcare that include poverty, lack of insurance coverage, linguistic challenges

S  3 times more likely to lack having a regular healthcare home

S  Less likely to be UTD on immunizations

S  Less likely to receive treatment for common medical illness (earaches, sore throats)

S  Have more school absences

S  More likely to use the ED for routine care

S  <50 % of children have a healthcare home

-Barriers: INSURANCE, lack of primary care providers, transportation, language, education)

California Health Insurance Coverage for Children 0-18 years

0%

10%

20%

30%

40%

50%

60%

California United States

Employer

Other Private

Medicaid

Other Public

Uninsured

Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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The ACA establishes a minimum Medicaid eligibility level of 138% of FPL for all children up to age 19.

Affordable Care Act

S  Estimated 3.2 million children can be expected to gain healthcare coverage; transition coverage for all children up to 138% of FPL to Medicaid for children up to age 19

S  Uninsurance rates expected to decline for children in all family income groups

S  Hispanic children will see the largest gains in coverage

S  Children may have more comprehensive coverage

but may have decreased access to care Access

Quality Cost Duderstadt, K. (2014). Promise of the Affordable Care Act 2014: Update on Uptake & Impact Across States, NAPNAP presentation

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Children on public insurance and accessing care

S  546 paired calls to 273 specialty clinics in Cook County, IL

S  Results: Significant disparities in provider acceptance of Medicaid-CHIP versus private insurance across all tested specialties

S  66 % of Medicaid-CHIP callers were denied appts vs 11% of privately insured callers

S  Among 89 clinic that accepted both insurance types, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children.

Bisgaier, J. & Rhodes, K.V. (2011).

What can we do?

S  Greater investments in preventive care; incentives for primary care providers

S  Future of CHIP authorization: Highlight barriers to coverage as well as differences in coverage between CHIP and marketplaces

S  Ongoing outreach and enrollment efforts to achieving additional coverage for children

S  Formation of integrated systems and the configuration of payment methods that an optimize access and decrease disparities

#2: Technology

S  Pressure and incentives for NP’s to integrate critical technologies into practices

S  Greatest challenge with EHR implementation and use will continue to be the integration and interoperability of records and systems

S  High costs of implementing and upgrading technology will have created disparities across practices

S  Increasing use of new technologies such as telemedicine and methods to promote on-line interactions with patients and their families

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Attributes of computer-based patient records Problem

Lists Measurement and

Recording of health status and functional

level

Logical basis for all diagnosis and conclusions

Linkage with all of patient’s clinical

records across settings and time periods

Widespread accessibility

Selective retrieval and formatting

Linkage to local and remote knowledge

sources

Decision support

Structures data collection

Aiding evaluation of quality and costs of

care

Flexibility and expandiability to meet evolving practice needs

Assurances of confidentiality

Institute of Medicine

Technology and Pediatrics

S  Growth data: Ability to record small changes (i.e. premature neonate)

S  Patient identifier: time of birth

S  Special terminology: pediatric preventative care & physical findings

S  Age-based normal ranges

S  Prescribing of medications

S  Immunization: mechanism for decision support

S  Parents’ requirements

S  Reporting: school or camp

S  Special privacy issues: adolescent, genetics, guardianship, abuse and neglect,

S  Registry links

S  National Policy Statements AAP Task Force on Medical Informatics, 2001.

Telemedicine

S  HealthPartners: employs NP’s through the internet to provide care of common conditions

S  Utilizes video conferencing and online chats

S  Provide convenience and increased access

S  Reported a 1-year savings of $900,000 in ED visits for diabetes care

Robert Wood Johnson Foundation, 2012

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#3: Medical Advances

S  New medical breakthroughs will enter the market rapidly, leading to vastly improved capacity for diagnosis and treatment

S  Costs to develop and use these new technologies will be significant and are likely to create disparities among the patients who benefit from new diagnostic, treatment, or preventive advances, and among practices that can afford them

S  The demand for comparative effectiveness research will grow as new technologies emerge

Headlines

#4: Changes in Healthcare Delivery System

S  Integrated systems of care will have developed

S  Significant investment in quality assurance will prevail which will lead to a publicly transparent network of healthcare quality data comparing practices.

S  Although increasing numbers of children will have insurance, growing disparities will exist

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Changes in Healthcare Delivery System

S Accountable Care Organizations (ACO’s)

S Patient Centered Healthcare Homes (PCMH’s)

S Community Clinics

S Health Insurance Exchanges

#5: Consumer-Driven Healthcare

S  Patients and their families will expect their needs to be prioritized by the healthcare system in terms of both, communication and convenience.

S  While actively engaged in their own healthcare, families will continue to need support and information from their health care professionals.

S  PNP’s will have extended their time and effort to respond to demands for added-value services such as on-line scheduling, vaccine or lab result reminders and referrals to reliable information and educational websites

#6: Pediatric Workforce

S  NP student debt will likely remain a significant burden

S  Pediatric NP residency training programs to develop to prepare for the realities and scope of everyday practice

S  Payment issues and the continued maldistribution of the pediatric workforce will remain pervasive challenges.

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Current Climate

S  Graduation rates of PNP’s has stalled

S  Greatest concentration of PNP’s in the New England and mid-Atlantic Regions

S  States that allow PNP’s to practice or prescribe independently do not consistently have a higher density of PNP’s per child population

S  Vulnerabilities of NP reimbursement, constraints on scope of practice

S  < 10 % of all NP’s are PNP’s

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Martyn, K.K, Martin, J., & Gutknecht, S .(2013). The pediatric nurse practitioner workforce: meeting the health care needs of children. Journal of Pediatric Health Care 27, 400-405.

What can we do?

S  Improved collection, research, and dissemination of APRN workforce data for planning and policy making

S  Implementation of pediatric advanced practice residency programs

S  Development of career progression initiatives

S  Standardization of licensure regulations, certification requirements, scope of practice, and legal recognition of APRN’s

S  Resources for quality outcome evaluation of innovative partnerships and practice models

NAPNAP Position Statement on Development of Nursing Workforce, 2013

#7: Disasters

S  More frequent and intensive disasters will likely occur as a result of imbalances in the Earth’s geophysical and geopolitical climate

S  As a result of these disasters, more families will face economic problems, be unemployed, and have less money to spend on their children and health

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Disaster Report Card

http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.8777053/k.F31D/Get_Ready_Get_Safe_Disaster_Report_Card.htm

www.savethechildren.org

#8: Globalism

S  New communication technologies will create broader opportunities to link pediatrics in a global network and facilitate efforts to share knowledge to address threats child health

S  The rapid spread of disease will worsen with increased movement of individuals across the globe.

S  The continued diversification of patient populations will result from increased immigration.

S  Pediatric practices will have needed to adapt to offer culturally effective services in ways that enhance child and family health and meet families’ needs.

S  “Medical tourism” will occur regionally and internationally as patients travel to obtain healthcare considered to be most appropriate in terms of cost, quality and availability.

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Largest Immigration Group

Children in U.S. Immigrant Families

Migration Policy Institute (MPI) Data Hub www.migrationpolicy.org

United States California

Ebola

What to tell children: ü They are safe ü Our health care system is among the best in the world for taking care of sick people ü Ebola is rare and does not exist everywhere. When cases are found, the person with the infection is taken to a safe place to be cared for so that he or she can get better and not make anyone else sick ü Doctors and scientists who know about Ebola are working hard to find ways to prevent or cure this illness. www.healthychildren.org

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What do you look for in a leader?

S  Someone whose direction you would willingly to follow

S  Honest

S  Forward-Thinking

S  Inspiring

S  Competent

Model The Way

S  Leading means you have to be a good example, and live what you say.

S  Earning the right and respect to lead through direct involvement and action

S  People follow the person first, then the plan

S  Best projects distinguished by relentless effort, steadfastness, competence and attention to detail

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Inspire a Shared Vision

S  What made the difference was the vision of how things could be and clearly painting this picture for all to see and comprehend” – Mark D’Arcangelo, Hitachi semiconductor

S  Envision exciting possibilities

S  Patients must believe that NP’s understand their needs and have their interests at heart

Challenge The Process

S  Look for ways to improve the team, taking interest outside of the organization, finding ways to stay current, networking and taking initiative to try new things” – Jennifer Cun, budget analyst at Intel

S  Change from the status quo

S  Search for opportunities to innovate, grow, and improve

S  Experiment and take risks by constantly generating small wins and learning from experience

Enable Others to Act

S  People respond more eagerly and become more cohesive when people felt part of the “we”

S  Foster collaboration and build trust

S  Each person should have a sense of ownership for his or her projects

S  Teamwork, trust, and empowerment

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Encourage the Heart

S  Recognize contributions

S  Show appreciation for people’s contributions

S  Create a culture of celebrating values and victories

S  Build a strong sense of collective identity and community spirit

Thank you!

References

S  Aiken, Linda (2010). Nurse for the Future. The New England Journal of Medicine 10.1056 NEJMp1011639. 103.

S  Archibald, M.M & Scott, Shannon (2012). The information needs of North American parents of children with asthma: a state-of-the-science review of the literature. Journal of Pediatric Healthcare, 28, 1, 5-13.e2.

S  Bisgaier, J., & Rhodes, K.V. (2011). Auditing Access to Specialty Care for Children with Public Insurance. New England Journal of Medicine, 364: 2324-2333.

S  Chiu, et. al (2012). Childhood Obesity and Dental Caries in Homeless Children. Journal of Pediatric Healthcare, 27, 4, 278-283.

S  Duderstadt, K. (2014). Promise of the Affordable Care Act 2014: Update on Uptake & Impact Across States

S  Edmunds, Marilyn (2012). Editorial: The Power of Professional NP Associations. The Journal for Nurse Practitioners, 9, (10) 766.

S  Foster, D. (2014). The advantages of internet healthcare providers. Retrieved from http://www.ehow.com/list_6635790_advantages-internet-healthcare-providers.html

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References

S  Freed, G., et al (2010). Pediatric Nurse Practitioners: Roles and Scope of Practice. Pediatrics, 126, 846-850.

S  Freed, G. et al (2010). Pediatric Nurse Practitioners in the United States: Current distribution and Recent Trends in Training. Journal of Pediatrics, 157, 589-93.

S  Goleman, Daniel (1998). What makes a leader? Harvard Business Review. 93-102

S  Kouzes & Posner (2007). The Leadership Challenge. 4th Ed.John Wiley & Sons, Inc. San Francisco

S  NAPNAP Position Statement on Development of Nursing Workforce. (2014). Journal of Pediatric Healthcare, 28, (2): A11-A12.

S  Savrin, Carol (2009). Development of the Nurse Practitioner Role Around the Globe. Journal of Pediatric Healthcare, 23, 5, 310-314.

References

S  http://www.childtrends.org/?indicators=asthma

S  http://www.childtrends.org/databank/indicators-by-topic-area/

S  http://www.census.gov/prod/2011pubs/acsbr10-05.pdf

S  http://kff.org/other/state-indicator/children-0-18/?state=CA

S  Institute of Medicine. The Computer-based Patient Record: An Essential Technology for Health Care. Dick, RS, Steen EB, Detmer DE, eds. Washington: DC National Academy Press; 1997

S  Task Force on the Vision of Pediatrics. Vision of Pediatrics 2020 Findings: Megatrends, Drivers, Scenarios, and Transformations. American Academy of Pediatrics. 2010

S  Task Force on Pediatrics. (2001). Special Requirements for Electronic Medical Record Systems in Pediatrics. Pediatrics, 108, [DOI: 10.1542/peds.108.2.513]

S  Robert Wood Johnson Foundation. (2012). Implementing the IOM Future of Nursing Report-Part III: How nurse are solving come of primary care’s most pressing challenges. Retrieved from http://www.rwjf.org/content/dam/files/rwjf-web-files/Resources/2/cnf20120810.pdf