Approximately 80 nurse practitioners attended AONP’s legislative day in support of House Bill 1013 by Rep. Josh Cockroft and Sen. AJ Griffin. We heard from a number of speakers, including AARP Oklahoma executive director Sean Voskuhl, before visiting with lawmakers about ideas to increase access to health care in the Sooner State.
HB 1013, which was introduced last year, aims to do away with the outdated requirement that NPs sign a collaborative agreement with a physician.
This is a common-sense solution to a real problem.
The truth is, our state is woefully short of primary care providers and that impacts the health of Oklahomans in substantial and measurable ways. We’re 49th in physician-to-patient ratio, and always in the bottom 10 in national health rankings. It’s time Oklahoma joined almost half the states in the country in giving NPs full practice authority.
HB 1013 passed the Oklahoma House of Representatives on a 72-20 vote last legislative session but failed to receive a hearing in the Senate Health and Human Services Committee. The measure is still active and we are urging legislators to pass it this year.
Nurse practitioners have been leading the charge to cut through Oklahoma’s needless red tape, and implement a reform that’s already working in almost half of all states. This issue has momentum now, with a number of advocacy and business groups joining in the fight.
House Bill 1013 must pass out of the Senate Health and Human Services Committee before April 12. If you’re tired of long drives or of waiting days for a primary care appointment, contact your state senator today and ask them to support and co-author HB 1013.
Time is running out to register for AONP’s legislative day at the state Capitol on February 27! We need you to join us to tell your elected representatives how nurse practitioners can help ease Oklahoma’s critical shortage of primary care providers.
For more than a year now, AONP has been working for the passage of House Bill 1013, by Rep. Josh Cockroft and Sen. AJ Griffin. The bill would free the profession from costly and needless collaborative agreements. That legislation remains stalled in the Senate Health and Human Services committee.
Now is the time to act to secure full practice authority!
The day will begin at 9 a.m. across the street from the Capitol at the Oklahoma History Center, 800 Nazih Zuhdi Drive. Attendees will hear from several speakers, then take a bus to the Capitol to visit with legislators. The event concludes back at the History Center with lunch.
We need to turn out in large numbers to make a final push to get HB 1013 across the finish line. Today, 76 of Oklahoma’s 77 counties are designated as primary care shortage areas. Nurse practitioners can do more to care for their neighbors. We just need the legislature to remove the unnecessary red tape and let us put our education and training to use.
Join us on February 27 to make that goal a reality!
As the legislative session gets underway, we’ll hear a number of arguments against full practice authority for nurse practitioners. Many of these arguments relate to patient safety, though those concerns are unfounded. Study after study has shown that utilizing a nurse practitioner as a primary care provider does not put patients at risk, and may increase health care access for many.
Here are some of the arguments you’ll hear in the coming months, as well as responses you can use to educate the public and allay any concerns they may have.
NPs simply want to play doctor, but without putting in the time that physicians do for education and training.
Nurse practitioners have at least a masters’ degree, and many have doctorates. In addition to their formal education, many NPs spend years working in clinical settings as registered nurses before achieving their NP certification. What’s more, they are not trying to “play doctor” or do anything more than NPs are trained to do.
Due to their lack of education and training, NPs are not qualified to make the best decisions for patients.
NPs know and understand their scope of practice. They know the limitations of their training and when to refer or consult with other professionals. Just like an ear, nose and throat specialist wouldn’t attempt heart surgery, NPs know what they are qualified to treat and what is outside their area of expertise. Many NPs currently run independent practices and they provide quality care for patients.
NPs practicing without physician oversight will create a patient-safety issue in Oklahoma.
Twenty-two states and the District of Columbia grant full practice authority to NPs. That’s almost half the country, yet we don’t hear about patient safety crises in those states. Several years ago, the National Governors Association undertook a review of the available research and concluded that:
“None of the studies in NGA’s literature review raise concerns about the quality of care offered by NPs. Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures. Moreover, the studies suggest that NPs may provide improved access to care.”
Further, a majority of states that employ full practice authority rank in the top half of the nation’s health rankings.
The best role for NPs is part of a team-based approach with a physician at the head of the team.
Nothing about full practice authority precludes nurse practitioners from working in a team-based setting. NPs are a vital part of many health care teams. Full practice authority simply means that nurse practitioners can practice as such without the necessary expense of paying for a collaborative agreement.
There’s no proof that NPs will open clinics in rural Oklahoma, and statistics show that NPs currently tend to practice where physicians are practicing.
NPs are currently clustered near physicians because they are required to have a collaborative agreement, and they face financial obstacles to opening their own clinics. In other words, they are practicing where they can currently find jobs.
Studies that have looked more in depth, though, have found that NPs are more likely than physicians to locate in rural areas. One study from Nursing Outlook found that:
“States granting NPs greater SOP [scope of practice] authority tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations. Our review indicates that expanded NP practice regulation can impact health care delivery by increasing the number of NPs in combination with easing restrictions on their SOP.”
“For the 17 states that did not restrict scope-of-practice laws governing nurse practitioners at the time of the study, 62 percent of the state’s population had high geographic accessibility to a primary care nurse practitioner,” said Peter Buerhaus, the study’s author. “In contrast, in the 21 states that fully restricted the practice of nurse practitioners, the percent of the population with high accessibility to a primary care clinician decreased considerably.”
NPs simply want to use legislation – not the education or training needed – to earn the privilege of practicing medicine.
Nurse practitioners don’t want to practice medicine — they want to practice nursing. That’s why many of them have spent tens of thousands of dollars and years of their lives to earn Doctor of Nursing degrees. Nurses treat specific ailments, like a general practice physician, but their treatment philosophy also encompasses the health and well-being of the individual as a whole.
If a physician has an agreement with an NP, but isn’t providing any real supervision, that physician needs to be reported to the board.
That argument isn’t really related to the issue of full practice authority. Rather, it’s a talking point the physician community uses to distract from the issue of utilizing full practice authority to increase access to care for all Oklahomans. The fact is, several nurse practitioners already own their own clinics in Oklahoma, and many more are providing services to Oklahomans every day with little or no oversight from their collaborating physicians. In fact, the law doesn’t even require oversight — it only requires a signed collaborative agreement. The problem is that NPs might pay thousands of dollars every month for that agreement. Those are funds that could be used to open new clinics, hire additional staff — or just considered income for work performed. Nurse practitioners are nationally certified and regulated by the Oklahoma Board of Nursing. The requirement for collaborative agreements is simply outdated red tape that is holding back health care in Oklahoma.
We know that full practice authority for nurse practitioners will increase access to health care, and that means an improvement in the health and wellbeing of residents. But it turns out that health care access is also a vital economic statistic.
Dr. John Leatherman, agricultural economist at Kansas State University’s Office of Local Government and lead author of the report, noted that health care access and education are two of the most important factors in attracting and retaining business and industry.
“Research has shown time and again that local health care and education are two enormously important factors for economic development,” Leatherman said, “and both can be positively or negatively influenced by local action or inaction.” He said the local health care system has sometimes been the “tie-breaker” in industry location decisions and that retirees view quality local health care as a “must have” local service.
The reality is our state does not have enough health care providers to meet our population’s needs. Texas ranks 47th among the 50 states in primary care access. And while Texas is busy worrying about whether APRNs should have to pay doctors to practice, other states like New Mexico are happily recruiting our Texas-trained APRNs to come to them. Why wouldn’t an APRN go to a different state where their competitors aren’t allowed to deny them the right to practice?
HB 1013, by Rep. Josh Cockroft and Sen. AJ Griffin, would allow nurse practitioners to put their full education and training to use caring for Oklahomans. That bill passed the Oklahoma House with an overwhelming, bipartisan vote before stalling in a Senate committee. The measure isn’t dead, though, and can move forward once the legislature reconvenes in February.
In addition to researchers in neighboring states, a number of free-market think tanks have pointed to the advantages of full practice authority. Current regulations, in many states, include burdensome red tape that does nothing to improve patient safety or outcomes. Jettisoning outdated regulations would improve health of both the citizens and the business environment. It’s a move that Oklahoma should make sooner rather than later.
In Oklahoma, more than 1 out of every 3 people you pass in the store or sit with in a movie theatre or restaurant are on a path to developing diabetes. Most of them don’t even know it.
That’s why awareness and early diagnosis are critical. Once diagnosed with diabetes, there is no cure. Many of our friends and neighbors are not aware of their risk, though Oklahoma has one of the highest diabetes rates in the nation.
In my work as a diabetes care specialist, I see every day how dangerous and painful diabetes can be if it’s undetected, untreated or uncontrolled. It’s not a problem that goes away. If left untreated, it only gets worse and could lead to blindness, amputations and more.
The disease sometimes shows few symptoms at first, but early diagnosis is key to successful treatment and avoiding serious complications in the future. Though there is no cure, healthy lifestyle habits can help to successfully manage the disease.
Everyone can reduce their risk and even those with prediabetes can slow its progress with a few simple steps.
Early detection is vital. If you have risk factors for diabetes, it’s important to have your blood glucose level tested. Make an appointment and chat with a medical professional today.
Diabetes is a problem that you can’t start treating soon enough.
Leah Melton is a nurse practitioner specializing in diabetes care. She is board certified in Advanced Diabetes Management through the American Association of Diabetes Educators. She practices in Norman.
Now the Oklahoma City VA is moving closer to putting those rules into practice.
Officials said the Oklahoma City VA is on the cusp of granting full practice authority to more than three dozen advance practice registered nurses.
Kerri Craft, associate director for patient care services at the Oklahoma City VA, and Siobhan Gower, credentialing and privileging supervisor at the local VA, explained that officials at the Oklahoma City Veterans Center has been amending their clinical bylaws and setting up the privileging process for nurse practitioners to be granted full practice authority.
“We’ve got 38 APRNs in our center, and our hope is to get all of them through the privileging process in the next few months,” Craft said.
Gower said that the privileging process for nurse practitioners will work much in the same way that it currently does for physicians.
“There are standardized privileging forms for different areas of concentration, like primary care, medicine and so on,” Gower said. “That form will be approved by a professional standards board and then it’ll go to the director of the center for final approval.”
Craft and Gower also said that pay scales have been adjusted. Nurse practitioners have the opportunity to make more once they move through the privileging process.
“We really hope that moving from a scope-of-practice approach to a privileging process with be a good recruiting tool,” Kraft said. “We’re looking to hire a number of additional APRNs from across the country in the coming years.”
That’s following a recent trend of using nurse practitioners and other APRNs to increase access to health care. In addition to the move at the VA to grant full practice authority to nurse practitioners, 22 states and the District of Columbia grant full practice authority to NPs, and the list continues to grow every year.
There are nearly 6,000 advance practice registered nurses who work for the U.S. Department of Veterans Affairs, not to mention thousands more who care for veterans in other facilities.
But access to medical care, even to basic primary care services, can be limited as the U.S. faces a shortage of providers. This is especially true in rural areas and VA facilities are no exception.
Though the nation as a whole faces this shortage of primary care providers, the need is particularly acute in Oklahoma, which ranks 49th among the states in physician-to-patient ratio.
The VA is expanding the role of nurse practitioners and actively recruiting new hires to serve veterans. The Oklahoma legislature can give the same rights and privileges to the nurse practitioners who are serving Oklahomans in communities across the state each day.
Lawmakers will have that chance in the upcoming legislative session. House Bill 1013 would grant Oklahoma nurse practitioners full practice authority. The bill was passed overwhelmingly in the House last year, but now awaits a hearing in a Senate committee.
The Association of Oklahoma Nurse Practitioners wrapped up a successful 23rd annual conference on Oct. 20 with a call for NPs to continue their advocacy for increased access to health care for Oklahomans.
“You are your own best advocate,” said Peter Jeffries, AARP national engagements director. “Go into meetings with legislators and tell your story about why we need full practice authority in Oklahoma. Access to care is critical, especially in small towns, rural communities and underserved areas.”
In all, nearly 400 nurse practitioners and students from Oklahoma and surrounding states attended the conference at the Sheraton-Reed Conference Center in Midwest City.
An Oklahoma House measure introduced in the 2017 legislative session, House Bill 1013 by Rep. Josh Cockroft and Sen. AJ Griffin, would have done away with the outdated requirements that restrict access to care from NPs.
“We are so grateful as lawmakers for the impact you have on everyday Oklahoma,” Cockroft told the conference. “There are tremendous challenges facing Oklahoma, particularly in health care and access to care, but I can breathe easier knowing you’re out there doing your work caring for Oklahomans.”
HB 1013 passed the Oklahoma House of Representatives on a 72-20 vote, but failed to receive a hearing in the Senate Health and Human Services Committee. That measure is still active and could be taken up in the 2018 session.
Griffin praised the nurse practitioners for their work in communities around the state.
“Nursing is a special calling,” she said. “Thank you for what you do for your neighbors and your communities. I hope we can make legislative changes to allow you to work at the top of your skill level. Rural Oklahoma needs you. We need you and your expertise.”
The conference also featured workshops and seminars on a range of health care topics, including respiratory infection, insulin therapy, sports medicine, infectious disease and more.
AONP President Toni Pratt-Reid said she is optimistic looking ahead to the 2018 legislative session.
“Each legislative session, we learn a little bit more about the legislative process, and the public and lawmakers learn a little bit more about what nurse practitioners do each day and how we can do more to care for Oklahomans,” Pratt-Reid said. “Our annual conference is a great opportunity to share what we’ve learned in the past year, and lay the ground work for the next year.
“We’re energized and ready to share our story with legislators and the public to keep building support for a measure that would increase access to health care for everyone in the state,” she continued. “Everyone in Oklahoma would benefit from full practice authority, and more people are starting to understand that every day. We can increase access to affordable care for Oklahomans without spending a dime of taxpayer money. It’s a win-win.”
Nurse Practitioner Hopes to Return to Rural Hometown
It’s common story in small towns across Oklahoma and the United States: kids leave for college and few return to build a life in the community where they grew up. Instead, they seek out better job prospects in larger cities. Even those who might want to return home don’t due to a lack of job prospects.
Stephanie Keesee doesn’t want that to be her story. After becoming a nurse practitioner, she knew she wanted to return home to care for her family, friends and neighbors. To do that, she’s planning to open her own clinic in her hometown of Holdenville.
“I was born and raised in Holdenville. This is where we live, on a ranch. We’re not moving,” Keesee said. “I want to serve the community I grew up in.”
Keesee earned her B.A. in nursing from the University of Oklahoma College of Nursing in 2005. She worked as an RN for a decade before earning her Masters of Nursing from OU and becoming a family nurse practitioner.
For the past year, she’s been living in Holdenville and commuting to work at Wellspring Family Clinic in Broken Arrow, while dreaming of opening a clinic closer to home in rural Oklahoma.
“Rural Oklahoma faces such a shortage of health care,” she said. “I don’t think people understand until you can’t get in to see a provider, whether an NP or physician. My brother’s girlfriend had to see a doctor last week and it took her two weeks to get in. A minor issue can become a serious issue if you’re waiting two weeks to get an appointment.”
Keesee moved one step closer to her dream earlier this year when she purchased a building for a clinic, which she plans to open next summer. The time is right, she said, because the two nearby providers will retire in the next couple of years.
But she still faces one major obstacle — finding an authorizing physician. In order to practice and prescribe medications, she must sign a collaborative agreement with a physician. Because she’s on leave and not currently working, she terminated her agreement with her previous collaborating physician.
“I was paying $500 a month out-of-pocket for that signature,” she said. “In almost two years, I’ve seen him once. It didn’t make sense to keep paying when I wasn’t working.”
So far, her search for a new collaborative physician isn’t going well, but she noted that the legislature could take action to do away with that outdated regulation and allow full practice authority for nurse practitioners before her clinic opens.
“I’ve contacted five physicians so far, and all of those have been dead ends,” she said. “But if the legislature takes action next session, then I won’t have to worry about it. I won’t have to worry about the payments, and I won’t have to worry about what happens if my physician retires or moves or dies unexpectedly. I could just take care of serving the people in this community.
“There’s an elderly population and a lot of young kids here,” she said. “They’re a majority SoonerCare population and it’s hard to find care. “
She stressed that one barrier to health care in rural Oklahoma wasn’t just a lack of providers. That issue is exacerbated by a lack of providers who accept SoonerCare, the state’s Medicaid program.
She cited her experience at the Wellspring Clinic.
“Once a week we’d have new SoonerCare patients come in. They were people who’d lost jobs or insurance and now they were on SoonerCare,” she said. “They’d be COPD (Chronic Obstructive Pulmonary Disease) patients who need inhalers to live. Their previous provider wouldn’t provide inhalers with SoonerCare, so now their condition was that much worse and they were desperate. It was all because they lost their job. We were one of the few clinics in the area that would take SoonerCare.”
Keesee is hopeful that, by this time next year, her clinic will be open and serving those patients who have to drive 30 minutes or more for care today.
“These are my friends and family and I want to care for them,” she said. “It’s one of the main reasons I became a nurse in the first place.”
Nurse Practitioner Finds New Way to Serve the Community
For Kerri Ellis, a nurse practitioner in Beggs, Oklahoma, caring for patients goes beyond treating a case of the flu or managing diabetes. For Ellis, serving patients means looking at all the challenges they face and building a strong and supportive community.
That’s why she started a library.
It’s not a full-size, brick-and-mortar library, but a Little Free Library. The library is a weatherproof box outside her clinic that can hold around 100 books. Anyone in the community is free to pick up or leave a book anytime. This library is open 24/7.
“This is a medically underserved, primarily indigent community with no recreational things for children to do, and certainly no library,” Ellis said.
She has been caring for residents in rural Okmulgee County since she bought the CliniCo rural health clinic in 2001. In that time, her clinic has provided health services to more than 8,000 patients of all ages
“I saw a story about Little Free Library, which started in Wisconsin and the idea just caught fire with me,” she said.
Ellis said there are currently 50,000 Little Free Libraries across the world – in every state and in 70 countries – so it fills a gap in Beggs since the nearest library is in Okmulgee, 23 miles away.
Starting the library is closely tied to caring for the health of her patients, she said, citing a 2014 policy statement form the American Academy of Pediatrics that recommends parent-child home reading starting at birth and continuing at least through kindergarten to encourage brain development and socioeconomic wellbeing.
“Kids who have access to books are more prepared to start school. It literally changes the brain,” Ellis said. “Social mobility is improved just by something as simple as having a book, and 60 percent of low-income households don’t have a book available.
“As a nurse practitioner, you’re so often trying to fix a problem, trying to fix something that is already broken,” she said. “This a chance to fix something before it’s a problem. The data is clear – having books improves kids’ development and their lives for years to come.
The grand opening isn’t until Sept. 23, but the local community has already responded to the Little Free Library with enthusiasm, donating more than 1,800 books in four weeks. The books offer something for every age and every interest. Because of limited space in the weatherproof box, she has shelves of books inside her clinic and tries to switch books out every day.
The program has been such a success that Ellis and her staff are able to give a free age-appropriate book to every child they see for a regular well-child visit. She has also applied to partner with another nonprofit, Reach Out and Read, which could generate more resources and support.
“What we do as nurse practitioners – a lot of people don’t understand it, and it’s difficult to explain. We take a more holistic approach and try to make sure we’re looking at the needs of the whole person,” she said. “We don’t just say ‘take this medicine.’ We try to make sure they have the resources to get the medicine and know where to go to get it and how to use it properly.
“By providing these books, we can do so much good. There’s so much science behind the benefits of reading. It’s something the whole community can see and benefit from, and it makes a huge difference,” she said.
The community of Beggs, for its part, has embraced the new Little Free Library wholeheartedly.
“We started a Facebook page for the library, and parents are posting what they call ‘shelfies,’ pictures of parents and kids together with their books,” Ellis said. “It’s just wonderful to watch the kids ride up on their bikes every day to look through the books and pick one to take home.”
The Grand Opening celebration is planned for 2 to 4 p.m. Saturday, Sept. 23 at CliniCo, 103 E Main St. in Beggs. Several local and state dignitaries are expected to attend the celebration, including state Sen. Roger Thompson, state Rep. Steve Kouplen and AONP Executive Director Benny Vanatta.
If you’d like to contribute, Kerri said she could use scholastic books or any bookstore gift cards to obtain new books for the pediatric-focused Reach Out and Read program. The CliniCo Rural Health Clinic mailing address is PO Box 478, Beggs, OK 74421.
She also encouraged other nurse practitioners to investigate the program for themselves.
“I would really love to see more NP-owned and run clinics start these programs all over our state, especially in rural areas,” she said. “It improves lives, including those of the library stewards!”
Nurse Practitioners More Likely to Serve Rural Areas
Receiving primary health care services can be an ordeal for some Oklahomans, particularly those living in rural areas of the state. As medical providers increasingly consolidate, rural residents find themselves driving farther for even basic health services.
A study from Montana State University indicates that allowing nurse practitioners to work to the full extent of their education and training could be a part of the solution.
The study, published in the January 2016 issue of Medical Care, the Journal of the American Public Health Association found that nurse practitioners are more likely than physicians to practice in rural areas.
Even more interesting, it found that rural residents’ access to health care differed from state to state depending on, among other things, a state’s scope-of-practice laws.
“For the 17 states that did not restrict scope-of-practice laws governing nurse practitioners at the time of the study, 62 percent of the state’s population had high geographic accessibility to a primary care nurse practitioner,” said Peter Buerhaus, the study’s author. “In contrast, in the 21 states that fully restricted the practice of nurse practitioners, the percent of the population with high accessibility to a primary care clinician decreased considerably.”
Oklahoma ranks 49th in physician-to-patient ratio, so the demand for health care already exceeds the supply, and this problem becomes more apparent in rural areas of our state.
Nurse practitioners have a master’s degree or doctorate and are trained to provide many health care services, but outdated state laws create barriers to them starting new clinics. Oklahoma’s nurse practitioners are an under-utilized resource, and they could be doing more to care for Oklahomans. It’s time that Oklahomans enjoyed that same access to quality health care that can be found in 22 other states.
“The point is that we can do better in terms of patient accessibility to primary care,” Buerhaus said. “This is not a nurse practitioner versus physician issue. It’s an issue that is driven by the question of how do we best expand access to health care using all available resources?”
To read more about the Montana State University study, click here.
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