NURSE PRACTIONERS OPTIMIZING OUR FUTURE

Karima Velji, RN, PhDNPAO, 2010NPAO, 2010

OBJECTIVESOBJECTIVES• Where have we come from? Why?y• Where are we now?• Where are we going?

• Optimizing our future….

Where have we come from?Where have we come from?1960's• First NP program established at the University of

Colorado. • First education program for NPs working in northern p g g

nursing stations began at Dalhousie University. • Canada’s health care system was experiencing:

– changing role of the nurse from generalist tochanging role of the nurse from generalist to specialist;

– a physician shortage (ratio 740:1) especially in rural areas; ;

– trend towards specialization in medicine, fewer MDs in primary care; and

– emphasis on the curative aspects of medicine.emphasis on the curative aspects of medicine.History slides source: NPAO website; Jane Sanders (2010)

Where have we come from?Where have we come from?1970's• Boudreau Report recommends expanded role of the RN

and first university program in Ontario to prepare expanded role RNs.

• First university based program to prepare expanded role RNs.

• NPAO established as an affiliated Interest Group of the ORNAO.

• CNA/CMA Joint Committee releases joint policy statement on the role of the NP.

• Ontario Council of Health releases The Nurse Practitioner in Primary Care.History slides source: NPAO website; Jane Sanders (2010)

Where have we come from?Where have we come from?1980's• First round of NP initiative falters.• NP education program closes at McMaster University.• NPAO continues to actively lobby to re-establish

educational programs in Ontario. Development of first ACNP Program "Expanded Role• Development of first ACNP Program, "Expanded Role Nurse" program – Neonatology.

• CNS-NP role implemented in Level 3 NICUs following p greduction in number of pediatric residents.

History slides source: NPAO website; Jane Sanders (2010)

Where have we come from?Where have we come from?1990s• HPRAC releases 8 recommendations in support of

legislative authority for PHCNPs. • Bill 127, the Expanded Nursing Services for Patients Act

is proclaimed.• NPAO expands its mandate to include all nurse• NPAO expands its mandate to include all nurse

practitioners. • Teaching hospitals express interest in ACNP role.

History slides source: NPAO website; Jane Sanders (2010)

Where have we come from?Where have we come from?1990's• Government announce a new Nurse Practitioner

Initiative to improve access to PHC. • Council of Ontario University Programs in Nursing

(COUPN) consortium develops the new PHCNP Program.Program.

• Post-Masters ACNP certificate programs Toronto and London.

• College of Nurses of Ontario (CNO) approves the Extended Class registration.

History slides source: NPAO website; Jane Sanders (2010)

Where have we come from?Where have we come from?2000’s• Approvals for Nurse Practitioner led clinics.• HPRAC - Bill 179 – expanding mandate for NPs. • Regulation 965 – PHA - lobbying on admit, transfer,

discharge elements.Removal of MAC oversight on NP• Removal of MAC oversight on NP.

History slides source: NPAO website; Jane Sanders (2010)

Where are we now?Where are we now?• We have grown from 1001 NPs (PHC) in 2008 to 1694

(1262 PHC 133 P di t i 307 d lt) i O t i(1262 PHC, 133 Pediatric, 307 adult) in Ontario.• Approvals for 26 NP led clinics. • Integration in all sectors; legislative barriers partially g g p y

removed.• Since 1974, 28 RCTs have consistently shown that

nurse practitioners are effective, safe practitioners and fcan positively influence patient, provider and health-

system outcomes. • While there has been a steady increase in the supply of

f il d t d titi th i till lfamily doctors and nurse practitioners ,there is still only one nurse practitioner for every 10 family physicians in the province.History slides source: NPAO website; Jane Sanders (2010); CHSRF mythbusters, 2009

Where are we now?Where are we now?• Canadians are highly satisfied with care provided by g y p y

nurse practitioners. A 2009 Harris/Decima poll of 1,000 Canadians found that:

i fi h b t t d b titi– one in five has been treated by a nurse practitioner;– majority would like to see the role expanded;– greater than three in four would be comfortable– greater than three in four would be comfortable

seeing one in lieu of their family doctor; and– four in five feel that expanding their roles would be an

effective way of managing healthcare costs.

(Source: CHSRF mythbusters, 2009)

Where are we now?Where are we now?HPRAC – Bill 179• Royal assent in December 2009, awaiting regulations.• Removal of historic barriers – e.g. broader range of

drugs and forms of energy.• Regulation 965 under the Public Hospital Act currently

limiting scope and potential system impact transfer oflimiting scope and potential system impact, transfer of patients.

• Advocacy to enable RN(EC)s to provide health services to hospitalized in-patients (without directives).

(Source: NPAO, 2010)

Cost of health careCost of health care• Today, health sector spending accounts for about 46 y, p g

cents of every program dollar. If left unchecked, cost drivers could push health care spending to 70 cents of every program dollar in 12 years Health sector expenseevery program dollar in 12 years. Health sector expense is projected to increase by $6 billion from 2009-10 to 2012-13.

Source of health expenditures slides: MOHLTC Ontario website (2010)

Per-Capita Health Spending by Age Group, 2007Per-Capita Provincial Government Health Spending, by Age Group, Ontario, 2007, Current Dollars

Age Group

Spending Per Person ($)1

Share of Population, 2007

Actual (Per Cent)

Share of Population, 2030

Projection (Per Cent)

<1 9,188.0 1.1 1.1

1 4 1 292 6 4 4 4 31–4 1,292.6 4.4 4.3

5–14 1,047.6 12.0 11.2

15–44 1,706.3 42.8 37.3

45–64 2,823.6 26.5 24.2

65+ 10,330.7 13.2 21.965 74 6 883 1 6 9 11 765–74 6,883.1 6.9 11.7

75–84 11,843.7 4.7 7.4

85+ 20,702.4 1.6 2.8

Total 3,127.0 100.0 100.01 Weighted average. Sources: Canadian Institute for Health Information, Statistics Canada and Ontario Ministry of Finance population projections (Fall 2009).

Demographic shiftDemographic shift• Currently, 13 percent of the population is 65 years of age

or older. By 2016, there will be six million seniors in y ,Canada, composing 16 percent of the population. In Ontario, there are now approximately 1.5 million seniors, representing 40 percent of Canada's seniors. That p g pnumber is expected to double by 2028 (Ontario Seniors' Secretariat, 2003).

• The demographic profile of Ontario is one of an agingThe demographic profile of Ontario is one of an aging society. In 2009, 6.5 percent of Ontarians were over the age of 75 years, up from 4.6 percent in 1991. Projections indicate that in twenty years 10 6 percent of theindicate that in twenty years, 10.6 percent of the population will be over 75 years old. The total dependency ratio (the ratio of the population aged 0-19 and 65+ to the population aged 20-64) will be up to 79 2and 65+ to the population aged 20-64) will be up to 79.2 percent.

MOHLTC Ontario (2010)

Demographic shiftDemographic shift• Dramatic increases in the number of seniors living in

l t i tit ti 38 t f d 24long-term care institutions. 38 percent of women and 24 percent of men 85 years and older live in an institution.

• For many seniors, home care is the preferred method of i i O i f l l d i LTC ldreceiving care. One in four people placed in LTC could

potentially be cared for in alternative settings.• 90 percent of older seniors living in long-term care

institutions suffer from a mental disorder In Ontario 88institutions suffer from a mental disorder. In Ontario, 88 percent of these institutions receive only five hours or less of psychiatric services per month for the entire resident populationresident population.

• Shortly after entering an LTC home, one in six residents receives a new antipsychotic drug that he or she was not taking before, and one in four receives a new drug fortaking before, and one in four receives a new drug for anxiety or sleep.

Quality Monitor OHQC (2010)

Wait timesWait times• Wait times for an LTC bed are too long — an average of

105 d th th th F l iti105 days, or more than three months. For people waiting while at home, the wait time is 173 days (almost half a year). Wait times have tripled since the spring of 2005.F il i di id l h t h t i ll d 53• Frail individuals who cannot go home typically spend 53 days in hospital waiting for placement. As a result, currently 16% of all hospital beds in Ontario are occupied by patients designated as ALC who do notoccupied by patients designated as ALC, who do not need to be in hospital.

• In 2009 25% of patients spent more time in the ED receiving care than the recommended target Thereceiving care than the recommended target. The majority of patients did not get to see a physicianwithin the timeframe recommended by national experts. About 6% of them left the emergency department beforeAbout 6% of them left the emergency department before being seen.

Quality Monitor OHQC (2010)

Primary carePrimary care• About 7.1% (730,000) of Ontarians continue not to have

f il d t Ab t h lf f th i di id la family doctor; About half of these individuals are actively looking but can’t find one.

• For people who already have a family doctor, only half th i d t th t d h i kcan see their doctor the same or next day when sick.

• Compared to 10 other countries, Ontario and Canadahave the worst record on timely access to primary care.

OAlmost nine in 10 Ontarians say they are waiting too long to see their doctor, and this indicator has gotten worse in the last three years.I th l t i th it l f f il• In the last six years, the per capita supply of family doctors has increased by 6.2%, and that of nurse practitioners by 82%.

Quality Monitor OHQC (2010)

Health promotionHealth promotion• Half of Ontarians are not getting enough exercise, one in

six are smoking and one in five are heavy drinkers.• Breastfeeding rates are increasing and teen pregnancy

rates are decreasing, but there is still room to improve.• One-quarter of the population does not get necessary q p p g y

health prevention services (e.g., pap tests, mammography and flu shots).

• •People with low incomes or poor education are at hi h i k f h lth b h i d t tti h lthhigher risk of unhealthy behaviors and not getting health prevention services.

• Only 13% of Ontario doctors routinely provide patients ith li t f di ti t k ith 46%with a list of medications taken, with 46% never

providing a list.• About one in five seniors aged 65 and over are on a

medication with potentially dangerous side effectsmedication with potentially dangerous side effects.Quality Monitor OHQC (2010)

Chronic disease managementChronic disease management• While complications from diabetes have decreased

significantly over the past five years, patients are stillnot getting the regular monitoring of their condition andrisk factors that they need.risk factors that they need.

• Only half of patients with diabetes have their eyes and feet examined and slightly fewer than half are getting themedication they needmedication they need.

• The number of patients who die within one year ofhaving a heart attack has improved slightly to one in 11,b t till d b ttbut we can still do better.

Quality Monitor OHQC (2010)

Quality - ECFAAQuality ECFAA• On June 8, 2010, the Excellent Care for All Act, 2010 (ECFAA)

received Royal Assent Beginning with hospitals the Act requiresreceived Royal Assent. Beginning with hospitals, the Act requires health care organizations to:– Develop and post annual quality improvement plans. – Implement patient and employee satisfaction surveys and a p p p y y

patient relations process. – Link executive compensation to achievement of quality plan

performance improvement targets. Develop declarations of values after public consultation– Develop declarations of values after public consultation.

– Create quality committees to report to each hospital board on quality related issues.

– Related amendments to Regulation 965 under the Public gHospitals Act (PHA) were made and filed to support ECFAA.

• The MAC would no longer be required to make recommendations to the board under s.7(2)(a)(v) of Regulation 965 under the PHA that relate to the quality of care provided by extended class nurses whorelate to the quality of care provided by extended class nurses who are hospital employees.

Quality Monitor OHQC (2010)

Where are we going?Where are we going?RNAO calls for:• Implementation of campaign commitment for funding

for 25 additional NP-led clinics. • Implementation of funding for 150 new Nurse.Implementation of funding for 150 new Nurse. • Practitioner (NP) Primary Health Care positions across

health centres, family health teams, emergency departments and other outpatient settingsdepartments, and other outpatient settings.

• The removal of legislative and regulatory barriers to enable RN(EC)s to practice to their full scope.

• Dedicated funding to enhance the management of chronic disease in Ontario.

RNAO (2010)

Optimizing our futureOptimizing our future• Appropriate numbers and utilization of NPs; funding pp p g

streams for the positions.• Removal of legislative barriers.• Examine and respond actively the drivers for inclusion of• Examine and respond actively the drivers for inclusion of

NP roles in primary and institutional settings.• Demonstrate value in enhancing access, quality, equity,

i t d t ff tiappropriateness and cost effectiveness.• Stay true to patient need and system focus and don’t

lose “nursing” component of the role.g