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.
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Federal and State Policy News
As advanced practice registered nurses (APRNs), clinical nurse specialists (CNSs) ensure high quality nursing care that is evidence-based and promotes patient safety, while improving patient outcomes and lowering health care costs. We play this important role across a variety of specialties based on patient population, setting, condition or type of care.
NACNS also recommends requiring documentation proving that a CNS has achieved competency in his or her specialty, regardless of academic preparation, such as an academic transcript, an earned certificate or a portfolio.
NACNS’ Board of Directors has approved a project which will analyze the available pediatric and adult/gerontology CNS competencies in light of the Family Across the Lifespan population that is noted as a population option for licensure in the APRN Consensus Model. This project is slated to begin after January 1, 2014. Please send your curriculum vitae or resume to firstname.lastname@example.org and reference the project consultant opportunity. Please send any questions to email@example.com.
While the Call for Abstracts deadline for our 2014 Conference, The Best Kept Secret - The Clinical Nurse Specialist Contribution to Quality Care to be held in Orlando, FL from March 6-8 is Wednesday closed on September 11, 2013… students still have an opportunity to respond!Student poster abstracts may be submitted through Monday, December 2, 2013. All submissions must be made online through our Abstract Management System. Please visit the submission site for all instructions and guidelines.
It is time to consider your plans to attend the NACNS 214 Conference. The conference offers the opportunity for you to network with your colleagues as well as enjoy the sunny resort environment of the Orlando World Center Marriott and of course, the many activities in Orlando. Conference registration and lodging information will be available soon. Room rates at the Orlando World Center Marriott will be available for $189/night for single or double rooms. For specific questions about registration or hotel accommodations, please contact the NACNS office at 215-320-3881 or firstname.lastname@example.org.We hope to see you in Orlando, FL in March, 2014!
Beginning September 30, Clinical Nurse Specialist for the iPad will be restricted to members and subscribers to the Journal. Your subscription to CNS includes 6 print issues per year, full online access to cns-journal.com, including archived issues, and now exclusive access to the CNS iPad App! As a member, it’s easy to continue access to issues of CNS for the iPad.
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The CNS Scholarship applications now have a due date of December 31, 2013. Winners will be notified by January 31, 2014. A poster identifying the winners will be able to be viewed at the CNS Foundation Silent Auction table in the Exhibit Hall. Please visit the CNS Foundation page to review the application criteria.
The CNS Foundation will host another Silent Auction at the 2014 NACNS Conference. We ask individuals and affiliates to submit prizes to be auctioned off during the conference. Electronics, jewelry, gift cards and crafts have sold well in the past. Please bring you items to the conference or mail them Kathy Baldwin, the foundation chair (7029 Brierhill Court, Fort Worth, TX 76132). Small, easily transportable items are recommended.
Be part of the first class of perioperative CNSs to take the CNS-CP exam between March 17 - April 16, 2014. Applications open October 1, 2013. If you test during this time, the fee is only $125, providing you significant savings over the regular exam fee. Listen to the CNS-CP webinar, where our team reviews eligibility, the application process, and the major subject areas that will be covered.
It is important that each and every eligible perioperative CNS consider taking the exam during the inaugural testing period. Find out more about the deadlines, fees and testing locations here.
Nursing Research and Practice, Hindawi Publishing Corporation has put out a call for papers on the Impact of APNs on Patient, Providers and Health Systems Outcomes. Please click on this link to learn how to submit your manuscript.
The U.S. Food and Drug Administration published a new regulation defining the term "gluten-free" for voluntary food labeling. This will provide a uniform standard definition to help the up to 3 million Americans who have celiac disease, an autoimmune digestive condition that can be effectively managed only by eating a gluten free diet.
The FDA recognizes that many foods currently labeled as “gluten-free” may be able to meet the new federal definition already. Food manufacturers will have a year after the rule is published to bring their labels into compliance with the new requirements.
The structure of the brain may predict whether a person will suffer chronic low back pain, according to researchers who used brain scans. The results, published in the journal Pain, support the growing idea that the brain plays a critical role in chronic pain, a concept that may lead to changes in the way doctors treat patients. The research was supported by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health.
“We may have found an anatomical marker for chronic pain in the brain,” said Vania Apkarian, Ph.D., a senior author of the study and professor of physiology at Northwestern University Feinberg School of Medicine in Chicago. Chronic pain affects nearly 100 million Americans and costs the United States up to $635 billion per year to treat. According to the Institute of Medicine, an independent research organization, chronic pain affects a growing number of people.
In this study, scientists used the structure of the brain’s white matter to predict whether a subject would recover from low back pain. “Pain is becoming an enormous burden on the public. The U.S. government recently outlined steps to reduce the future burden of pain through broad-ranging efforts, including enhanced research,” said Linda Porter, Ph.D, the pain policy advisor at NINDS and a leader of NIH’s Pain Consortium. “This study is a good example of the kind of innovative research we hope will reduce chronic pain which affects a huge portion of the population.” Low back pain represents about 28 percent of all causes of pain in the United States; about 23 percent of these patients suffer chronic, or long-term, low back pain.
Scientists have thought the cause of low back pain could be found at the site of injury. However, recent studies suggest that the brain may be more involved with chronic pain. Dr. Apkarian and his colleagues addressed this by scanning the brains of 46 people who had low back pain for about three months before coming to the hospital but who had not had any pain for at least a year before. The researchers scanned the subjects’ brains and evaluated their pain with doctor’s examinations and questionnaires four times over a period of one year. About half of the subjects recovered at some time during the year; the other half had pain throughout, which the researchers categorized as persistent.
Previously, the Apkarian laboratory showed that the volume of grey matter in the brains of the same subjects who had persistent pain decreased over the same year. Grey matter describes the area of the brain where the central bodies and branched antennae, or dendrites, of nerve cells reside. They also showed that brain activity could be used to predict whether a subject recovered or experienced persistent pain.
In this study, the researchers used a scanning technique called diffusion tensor imaging (DTI) which measures the structure of white matter, the nerve cell wires, or axons, which connect brain cells in different parts of the brain. They found a consistent difference in white matter between the subjects who recovered and the subjects who experienced pain throughout the year. “Our results suggest that the structure of a person’s brain may predispose one to chronic pain,” said Dr. Apkarian. In agreement with this idea, the researchers also found that the white matter of subjects who had persistent pain looked similar to a third group of subjects known to suffer from chronic pain. In contrast, the white matter of the subjects who recovered looked similar to that of healthy control subjects.
To test this idea further, the researchers asked whether the white matter differences they saw during the initial brain scans predicted whether the subjects would recover or continue to experience pain. They found white matter brain scans predicted at least 80 percent of the outcomes. “We were surprised how robust the results were and amazed at how well the brain scans predicted persistence of low back pain,” said Dr. Apkarian. “Prediction is the name of the game for treating chronic pain.” The nucleus accumbens and the medial prefrontal cortex are two brain regions thought to be involved with pain. Further examination of the brain scans suggests that the white matter structure connecting these brains regions is different between the subjects who recovered and those who had persistent pain.
Federal and State Policy
Over the past decade, in some sections of the country emergency medical services has piloted an expanded role for paramedics, that of “community paramedic” (CP). This role builds on the skills and preparation of the paramedic, with the intention of fulfilling the health care needs of those populations with limited access to primary care services. Although the origin of the CP is rooted in rural settings in Canada, Australia and New Zealand, some of the CP practice in the United States are taking place in cities like Fort Worth, Pittsburgh, Raleigh-Durham, and San Francisco. The CDC reports that 46,000 public health jobs have been lost in the last four years. Use of the CP is perceived as innovative and filling an unmet need - taking care of those frequent users of the health care system who are uninsured or underinsured/Medicaid.
Currently, all CPs work under the direction of a physician and generally with the use of protocols - use of protocols is not evident in clinic settings. This expanded role might include helping frequent 9-1-1 callers access primary care or social services instead of emergency department (ED) care; making home visits to check on patients recently discharged from the hospital or ED; checking on individuals with certain types of chronic conditions, or providing immunizations or other disease prevention services. Funds to support demonstration projects have come from the federal Office of Rural Health Policy and from CMS Innovation Grants.
The legislative/regulatory activity related to community paramedicine has picked up significantly in the past three to four years. Minnesota became the first state to recognize this role in statute in 2011 (effective 2012) and was successful in it being added to the list of Medicaid-approved services. In 2013, a similar bill was signed into law in Missouri, as well as a resolution passed in the North Dakota legislature authorizing a study of the feasibility and desirability of the practice. Pennsylvania has formed a task force to recommend the best model for this role in that state.
The CP movement continues to pick up steam. In a new report released this month, the University of California - Davis Institute for Population Health Improvement recommends that California launch pilot programs to test a new model of community-based health care that would expand the role of paramedics under certain circumstances. In a new model of community-based care, paramedics, after undergoing additional training, would function outside of their usual emergency response and transport roles to facilitate more appropriate use of emergency departments and to increase access to primary care for medically underserved populations. The complete report - "Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care" - is available on the UC Davis Institute for Population Health Improvement website.
Interestingly, the EMS community is moving away from using the term "community paramedic." The newer concept that is being promoted is "mobile integrated healthcare". Apparently, it is not EMS-centric. It is community-based and multidisciplinary including physicians, RNs, APRNs, home health, hospice, PAs, PT/OT type services, and, yes, EMS/paramedics.
In 2010 the National Committee for Quality Assurance (NCQA) that developed the Patient Centered Medical Home decided to open the program to nurse-led practices in states that allow these clinicians to provide the full range of primary care and practice independently. NCQA states on its website that Physician Assistants and Nurse Practitioners are eligible to be listed as part of a recognized practice if they manage their own panel of patients.
Recently NACNS has written to NCQA to request that they recognize CNSs as eligible practitioners to become recognized as a Patient Centered Medical Home (PCMH). The CNS provides care from a wellness to illness perspective and may contribute much in the care of chronic medical conditions in the Medical Home. NCQA has stated that if a practice can demonstrate that it provides whole person care and meets the other elements of the joint principles (see below) for most of its patients (at least 75 percent), it can be eligible for PCMH recognition by NCQA even if it is not a traditional primary care practice.
NACNS has reviewed the Joint Principles and indeed many CNSs meet most of the Principles. We will be following up with NCQA and keep you informed of their decision.
The Centers for Medicare & Medicaid (CMS) announced that they are postponing the implementation of the durable medical equipment (DME) face-to-face signature requirement until sometime in 2014.
Section 6407 of the Accountable Care Act established a face-to-face encounter requirement for certain items of DME. The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. CMS has twice postponed implementation of this rule.
While this is a statutory requirement that CMS cannot change, NACNS stated in a letter written to CMS in September of 2012 that we “cannot support any of the proposed options because of this fundamental flaw, and urges reconsideration of this wasteful and unnecessarily narrow requirement.” In addition, “There is no evidence that requirements for physician oversight or supervision increases quality or reduces fraud. We do know that unwarranted requirements for physician supervision lead to delays in care and duplication of services.”
The Centers for Medicare & Medicaid Services (CMS) issued guidelines for admission and medical review criteria for hospital inpatient services under Medicare Part A. They clarified that individuals who are not physicians--such as physician assistants, residents or registered nurses–can write the order to admit a patient as long as the documentation of the order complies with state law, hospital policies and medical staff bylaws. This guidance applies to all inpatient hospital and critical access hospital (CAH) services.
CMS states that "At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital bylaws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient.” In such cases, the order must identify the qualified "ordering practitioner" and have the ordering practitioner or another practitioner qualified to admit inpatients authenticate (sign, date and time) the order prior to discharge.
The Agency for Healthcare Research and Quality (AHRQ) has developed a new website, AHRQ Health Care Innovations Exchange with resources and tools for improving health care. http://www.innovations.ahrq.gov/. The Innovations Exchange assists with solving problems, improving health care quality, and reduce disparities by providing evidence-based innovations and Quality Tools, viewing new innovations and tools published biweekly and learning from experts through podcasts, videos and articles.
The website allows one to identify solutions by Disease or Clinical Category, Setting of Care, Stage of Care, Organizational Process, QualityTool Topics, Patient Care Process, Patient Population, Quality Improvement Goals and Innovations by State.
The website is an excellent resource for CNSs leading quality improvement teams and implementing new processes to improve care. It is also a great resource for students. These innovations can also be used to write business plans.
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.