The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions. If you have any questions or wish to advertise in this publication – please contact Emily O'Connor at email@example.com.
As this newsletter goes to press, Senate Majority Leader Mitch McConnell (R-KY) stated that if he is unable to obtain 50 votes for the Senate’s version to rewrite the Patient Protection and Affordable Care Act (ACA), he will have to draft a more modest bill to stabilize the ACA’s existing insurance markets. McConnell’s bill, the Better Care Reconciliation Act of 2017 (BCRA), still is being crafted and amended. Introduced in the Senate on June 22, BCRA is similar to the House of Representatives’ bill, the American Health Care Act (AHCA), H.R. 1628, which passed on May 4.
Both the Senate and House bills are plans to repeal and replace the ACA. Each version contains deep cuts to Medicaid, repeals the ACA’s taxes and many of its mandates, and reshapes ACA’s subsidies. The non-partisan Congressional Budget Office (CBO) scored BCRA (i.e., provided a cost estimate), finding over the next decade a $772 billion reduction to the safety-net Medicaid program in the Senate bill, versus an $834 billion cut in the House bill. Also BCRA has substantive cuts to the subsidies – which were designed to make private insurance premiums and cost-sharing affordable for low- and moderate-income families – with $424 billion cut in the Senate bill, versus a $276 billion cut in the House bill. The decreases are “paid for” by repealing ACA taxes on wealthy families and on special interest groups. The BCRA provides $541 billion in such tax benefits, and the House provides $664 billion.
According to the CBO, both the Senate and House bills would cause millions of people to become uninsured within a decade, leaving about 49 million people uninsured by 2026. The Senate bill would cause 22 million to lose coverage, while the House bill would force 23 million to become uninsured. One cost effect of the reductions is that BCRA would reduce federal spending over the period of 2017-2026 by $321 billion, $202 billion more than the reduction that would result from the AHCA.
The CBO projects that BCRA would reduce premiums in the individual market as compared to current law but would dramatically increase out-of-pocket spending for cost-sharing. CBO predicts that many lower-income people would not consider BCRA insurance worth buying, thus implying that more people will turn to high-cost emergency departments for care, increasing uncompensated care, and squeezing providers' margins. BCRA would raise the cost of coverage significantly for older people as it reduces costs for younger people.
Similar to the ACHA, BCRA permits states to opt out of the ACA's mandated essential health benefits (EHB), which could then allow insurers to turn away patients who need maternity care, mental health treatment, chemotherapy, and emergency care. Additionally, waiving EHB could affect the more than 150 million people with employer-sponsored insurance who gained federally guaranteed protections against catastrophic costs in employer plans. For example, if a state chooses to drop prescription drug coverage from EHB, employees could face annual or lifetime caps on their drug coverage. For those with high-cost or chronic conditions, a cut to covered benefits could mean choosing between forgoing needed care and racking up devastating debt.NACNS issued a statement from Board President Vince Holly, MSN, RN, CCRN, CCNS voicing the association’s concerns that the proposed BCRA health reforms should prioritize patients, not reduce coverage.
The 2018 NACNS Annual Meeting will be here sooner than you think! It is time to start planning for this excellent conference – the only national conference that focuses on the clinical nurse specialist! Join us from February 28 to March 3 and explore our conference theme – Putting the Pieces Together: CNSs Bridging the Gaps in Health Care at the Renaissance Austin Hotel.
Austin is a beautiful city which holds the official motto as the “Live Music Capital of the World.” If you are in interested in music of any type, this is the city for you. As is the case in many Texas towns, Austin is also known for its hospitality, barbecue and charm!
2018 brings many positive changes for our conference attendees!
NEW: Expanded Program
NEW: Additional Workshops
NEW: More Pharmacology
NEW: Increased Focus on Quality
Three exciting webinars will be held in August and September.
August 15, 2017
September 6, 2017
September 20, 2017
Building on the work of the original NACNS Cost and Outcomes Task Force, the 2016-2017 NACNS Practice Committee developed an invaluable tool for the CNS – the NACNS Cost Analysis Toolkit. Released last month, this toolkit is designed to guide clinical nurse specialists in designing and capturing costs related to CNS-led initiatives to improve patient care and safety. No longer can CNSs rely on informal evaluation of the care we provide, the CNS must take cost savings into account.
Through their direct work with patients and families, nurses at the bedside and hospital and health system leaders, clinical nurse specialists are uniquely prepared to assess, analyze and improve the business of health care while continuing to put the patient first. The CNSs ability to translate value impact in the clinical setting is crucial. Today’s health care landscape is ever-changing. Initiatives to improve patient care and safety must take cost savings into account.
The Cost Analysis Toolkit includes:
5. NACNS Provides Comments on ANA Position Statement: The Ethical Responsibility to Manage Pain and Suffering
The American Nurses Association (ANA) recently closed its public comment period on a position statement, The Ethical Responsibility to Manage Pain and Suffering. This statement addresses the core ethical principles surrounding the management of pain and suffering and builds on the premise that nurses have a duty to relieve pain and suffering. The statement also addresses the opioid crisis and the ethical issues nurses face.NACNS’ Opioid/Pain Management Task Force reviewed and analyzed the statement and drafted comments in an effort to clarify some of the questions the position statement raised. These remarks, on behalf of the NACNS Board of Directors, were submitted during ANA’s call for public comments.
The Minnesota Affiliate is planning its fall conference on October 27, 2017 at the Radisson Hotel in Roseville. This year’s theme will be Growing Stronger Together – Influence of the Clinical Nurse Specialist. The Minnesota Affiliate welcomes CNSs from across the country to attend, network and learn from each other. CNSs can earn pharmacology credits in some of the sessions.
Susan Sendelbach, PhD, APRN-BC, CCRN received the first annual Mary Fran Tracy Excellence Award for her dedication and exceptional work to improve patients care, nursing and system improvements.
Minnesota NACNS elected a new board to lead the affiliate. They are:
Health care facility leaders can help prevent health care-associated Legionnaires’ disease by developing and using an effective water management program. A team, which can include infection control practitioners, facility managers, hospital administrators, quality assurance staff, or others, should be established to implement the program. These leaders can also work with providers to help them identify cases of Legionnaires’ disease and potential exposure sites. CDC’s updated water management program toolkit helps health care facility leaders identify buildings or devices that are at increased risk for growing and spreading Legionella, while CDC’s updated fact sheet for clinicians describes how to diagnose patients. Access these and other resources at www.cdc.gov/legionella.
Fifty-one percent of all opioid prescriptions in the United States are written for people with anxiety, depression, and other mood disorders, according to a new study that questions how pain is treated. The study found that this population – who also are at increased risk of abusing opioids and of suicide – received more prescriptions than the general population.
Of adults in the study who were diagnosed with mental health disorders, 18.7% use prescription opioids, compared with only 5% of people without those diagnoses. Researchers analyzed data on 51,891 non-institutionalized adults from the nationally representative Medical Expenditure Panel Survey (MEPS). In the MEPS prescription drug data, the most common oral opioid prescriptions were hydrocodone with acetaminophen, tramadol, and hydrocodone. Opioid users with mental health disorders were likely to be middle-aged, female, white, and unmarried. They received opioids predominantly for musculoskeletal problems, unclassified diagnoses, and undefined non-traumatic joint or connective disease.
Higher opioid use among those with mental health disorders persisted across key variables, including cancer status and various levels of self-reported pain. Differential prescribing may be a function of the patients' advocacy for themselves. It also might be because there is no objective assessment of opioid efficacy.There are various guidelines suggesting that opioid prescribing should be based on functional outcomes such as activities of daily living and physical function, not on self-reported satisfaction. The study emphasizes the need for careful assessment of prescription opioid use and attention to pain management in individuals with mood and anxiety disorders.
The incidence of multiply recurrent Clostridium difficile infection (CDI) is increasing at more than four times the rate of CDI in general, according to results of a retrospective cohort study published online in the Annals of Internal Medicine. CDI affects nearly 500,000 individuals annually in the United States, at a cost of more than $5 billion. Recurrence within 8 weeks of initial infection is common, and some patients suffer more than one event.
According to the latest Vital Signs report by the Centers for Disease Control and Prevention (CDC), opioids prescribed in the U.S. peaked in 2010, then decreased each year through 2015. The amount of opioids prescribed was at 782 morphine milligram equivalents (MME) per capita in 2010 and then declined to 640 MME per capita in 2015, which still is enough for every American to be medicated around the clock for three weeks.
The CDC study shows that half of U.S. counties had a decrease in the MME prescribed per person from 2010 to 2015. In 2015, six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. This wide variation suggests inconsistent prescribing practices among health care providers and that patients receive different care depending on where they live.The variation from county-to-county also highlights the need for health care providers to consider evidence-based guidance when prescribing opioids, such as CDC’s Guideline for Prescribing Opioids for Chronic Pain.
Two common antibiotics can help hospital outpatients heal from small skin infections involving Methicillin-resistant Staphylococcus aureus, according to a recent study published in the New England Journal of Medicine. Funded by the National Institute of Allergy and Infectious Disease, the study found that clindamycin and trimethoprim-sulfamethoxazole were equally beneficial in treating small skin abscesses after drainage, with a cure rate of 82% - 85% compared with 63% for patients who received a placebo. The authors note that possible antibiotic-related side effects should be taken into account when deciding treatment.
The National Center for Health Workforce Analysis (NCHWA) has contracted with the Census Bureau to conduct the 2018 National Sample Survey of Registered Nurses (NSSRN). In the 2018 NSSRN, all four APRN roles – including CNSs – will be included in the survey. NCHWA plans to separate the results for each of these APRN roles and report results individually at the national, regional, and state levels. Reporting, however, will depend on the number of APRN respondents to the survey. Gaining the cooperation of those who are sent the NSSRN will be key to ensuring high quality data for the study. As an endorser of the NSSRN, NACNS will be highlighted in all materials sent to the nationwide sample of 100,000 registered nurses.The Census Bureau currently is seeking public comment on ways to enhance the quality, utility, and clarity of the NSSRN information to be collected in 2018.
The Food and Drug Administration (FDA) recently announced "more forceful steps" it is taking to deal with the ongoing opioid addiction crisis. Looking at all facets of this complex issue and collaborating on various approaches, FDA next steps include forming a new steering committee and asking the public to share their ideas and experiences in online forums and at an upcoming two-day meeting scheduled in July.
The public workshop will address the challenges in using the currently available data and methods for assessing the impact of opioid formulations with abuse-deterrent properties on opioid misuse, abuse, addiction, overdose, and death in the post-market setting. The goal of the meeting is to discuss ways to improve the analysis and interpretation of existing data, as well as the opportunities and challenges for collecting and/or linking additional data to improve national surveillance and research capabilities in this area.
All materials from the public workshop are accessible online, including the FDA issues paper: Data and Methods for Evaluating the Impact of Opioid Formulations with Properties Designed to Deter Abuse in the Postmarket Setting.
On July 7 Health and Human Services Secretary Tom Price named Brenda Fitzgerald as director of the Centers for Disease Control and Prevention. Fitzgerald is an obstetrician-gynecologist currently serving as Georgia's Public Health Commissioner and president-elect of the Association of State and Territorial Health Officials. Fitzgerald previously served as president of the Georgia OB-GYN Society and as a health care policy advisor for former House Speaker Newt Gingrich (R-GA) and former Senator Paul Coverdell (R-GA).
President Trump nominated Dr. Jerome Adams, the health commissioner of Indiana since 2014, to serve as the 20th U.S. Surgeon General. If confirmed by the Senate, he would serve a four-year term. Adams replaces Dr. Vivek Murthy, who was appointed during the Obama administration and was unexpectedly dismissed in April before the end of his term.
Adams was confirmed as Indiana health commissioner when Vice President Mike Pence was the state's governor. He is a trained anesthesiologist and currently serves as assistant professor of clinical anesthesia at Indiana University School of Medicine.
As Indiana health commissioner, Adams garnered national attention for his handling of an HIV outbreak in Scott County, a rural community in the state. The outbreak was allegedly caused by people using used needles to inject the prescription painkiller Opana. Adams led the implementation of a needle exchange program to help curb the outbreak. Considering Adams' expertise and experience tackling the opioid epidemic, it's likely he will work to combat the issue as surgeon general if he is confirmed.
The Department of Health and Human Services (HHS) is soliciting written comments on the Healthy People (HP) 2030 proposed framework, including the vision, mission, overarching goals, plan of action, and foundational principles. Every ten years, through the HP initiative, HHS leverages scientific insights and lessons from the past decade along with new knowledge of current data, trends, and innovations to develop the next iteration of national health promotion and disease prevention objectives.
Since 1979, HP has set and monitored national health objectives to meet a broad range of health needs, encourage collaborations across sectors, guide individuals toward making informed health decisions, and measure the impact of prevention and health promotion activities. In order for comments on the proposed framework to be considered, they must be submitted by September 29, 2017.
In bipartisan fashion, the Senate Finance Committee (SFC) advanced legislation aimed at improving care for people with chronic conditions. The bill, S.870 - Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, now will be scheduled for consideration on the Senate floor.
The SFC considers this bill a “transformational” reform to Medicare as it gives a new focus on providing efficient treatment for chronic conditions, in addition to primary care services, hospitalizations, and prescription drugs. NACNS and the APRN Workgroup, one of the coalitions in which NACNS is a member, have been closely following this legislation for nearly two years.CHRONIC is aimed at reducing costs associated with chronic illness by giving people greater access to telehealth services, promoting care coordination between providers, and expanding value-based payment models. For example, the measure would create a voluntary pathway for people to join accountable care organizations, which could make it easier for providers to coordinate care for those patients. The bill also takes steps to improve care coordination for patients who are eligible for both Medicare and Medicaid and expands an Affordable Care Act pilot program that enables providers to offer primary care services at home to people with multiple chronic illnesses.
Resources of Interest
The National Quality Forum (NQF) is launching a new initiative to address the nation’s escalating opioid epidemic. NQF’s National Quality Partners (NQP) will bring together experts from NQF’s membership and from across the nation to develop a practical resource to help healthcare practitioners better manage their patients’ pain while reducing the risk of opioid addiction.
NQP will model the new Opioid Stewardship Action Team after other successful efforts to address national healthcare challenges. Last year, NQP issued a playbook to help hospitals strengthen antibiotic stewardship programs and released an issue brief to help providers, communities, and policymakers ensure that the preferences and values of individuals with advanced illness are at the center of their care decisions. Physicians, nurses, consumers, and other Action Team members, will build on current public- and private-sector efforts to address the opioid epidemic, focusing on improving clinicians’ prescribing practices.
In addition to improving clinicians’ prescribing practices, the Action Team will identify strategies and tactics for managing care of individuals who are at high risk of becoming dependent on opioids. The Action Team will also advance quality measures that support prescribers. In 2017, NQF endorsed its first measures that address prescribing opioids at high dosage or from multiple providers among patients without cancer. The NQP opioid stewardship playbook will be available in March 2018.
Congress passed the Protecting Our Infants Act of 2015 to respond to the unmet needs of pregnant women with opioid use disorder (OUD) and to infants born with neonatal abstinence syndrome (NAS). The law mandated the Department of Health and Human Services (HHS) to reduce the gaps in research, to develop guidance of best practice to treat NAS and to coordinate federal efforts.
HHS’s Substance Abuse and Mental Health Services Administration (SAMHSA) announced the availability of the updated Protecting Our Infants Act: Final Strategy – 2017. The report includes strategies for:
According to a new report from the Agency for Healthcare Research and Quality (AHRQ), hospitalizations involving opioid pain relievers and heroin increased 75% for women between 2005 and 2014, a jump that significantly outpaced the 55% increase among men.
AHRQ’s report, which provides the most current national rates on opioid-related hospitalizations and emergency department visits, also includes data illustrating wide variation by state. Among those findings:
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.