Eileen M. Sullivan-Marx, PhD, RN, FAAN Associate Dean for Practice & Community Health & Aging Policy Fellow University of Pennsylvania School of Nursing

 American Political Science Association  Atlantic Philanthropies  McMenamin, P. (2010). Some utilization and revenue variations in the direct billing Medicare Part B practices of APRNs. Unpublished draft. Senior Policy Fellow, American Nurses Association.

 Nurse Workforce  Advanced Practice Registered Nurses  Nurse Innovation Models  Programs for All-Inclusive Care of Elders (PACE)

 Licensed by state  3,063,163 RNs; 5.3% increase from 2004  Licensing Exam- NCLEX ◦ London, Hong Kong  884 per 100,000 persons  Most employed in hospitals  8% with advanced degrees  50% with BSN  88.4% white, 94.3% women  /initialfindings2008.pdf /initialfindings2008.pdf

 By 2020, the demand for RNs will be 2.8 million equaling a shortage rate of 29% Bureau of Health Professions, July, 2002

 Nurses should practice to full extent of education  Education should work together for seamless nurse career ladder – 80% BSN by 2020  Nurses should be full partners in redesigning health care  Effective workforce planning and policy making require better data collection and information infrastructure.

 Establish professional nursing roles in places where society lives/works ◦ Students can learn and seek jobs in these settings  Maximize benefits / Minimize costs ◦ Reframe care not by place but by skills and service  Enable nurses to control practice ◦ Payment of nursing care needs to be visible, transparent, fair, and based on outcome incentives  Foster and recognize independent decision-making by basic and advanced practice nurses ◦ Eliminate “medical” decision making orders, payment convolutions  Establish quality in community care as a core competency for all nurses  Embrace family/patient centered care within a team of providers with nurses as leaders in care  Lead the return and renewal of public health nursing

 Nurse Practitioners ◦ 46, 328 (1992) ◦ 63, 191 (1996) ◦ 85, 000 (2000) ◦ 141,209 (2004) ◦ 138,558 (2008)

 Lack of consistent visibility of APRNs in Medicare Fee Schedule  Direct to 85% physician rate  “Incident to” Billing  Nursing Home Admission  PACE, Home Care

Medicare Part B APRN Approved Charges and Services, Selected Calendar Years Role Quantity all APRNsapproved charges$1,377,657,548$1,413,208,645$1,681,765,201 $1,909,588,894 approved services28,570,72630,097,96231,448,84934,797,121 NPsapproved charges$710,858,569$791,033,224$897,967,022 $1,055,243,057 approved services22,373,13623,845,21425,016,30328,193,018 CRNAsapproved charges$620,968,979$578,527,445$737,992,696 $802,831,472 approved services5,088,4265,212,3255,368,9245,575,132 CNSsapproved charges$44,847,246$42,553,889$44,491,920$50,074,618 approved services1,080,0371,009,5881,027,951988,260 CNMsapproved charges$982,754$1,094,087$1,313,563$1,439,747 approved services29,12730,83535,67140,711

InterdisciplinaryTeam In-Home Services Day Health Care Center & Social Services Primary Care & Pharmacy Services Skilled Nursing Facility Care Rehabilitative & Activity Services Specialty – Behavioral Health, Podiatry, Dentistry Transportation Services Acute Hospital Care MEMBER/ FAMILY Living Independently for Elders (LIFE) Nurse Led Integrated Model of Care

 Owned and operated – Penn School of Nursing  Director of Nursing & Member Services  Primary Care – Nurse Practitioners  Geropsychiatric Nurse  Home Health Nurse Practitioner  Home Care Nurses  Day Center Triage Nurses

 Variation in distribution of nurse workforce  Address visibility and data accuracy for APRNs in Medicare and private insurer payment systems  Consider Future of Nursing Recommendations  Include Nurse Innovative Models that Address High-Value Care ◦ PACE model at Penn Nursing (LIFE) ◦ Nurse Managed Centers ◦ Transitional Care Model