Author Jill Gilliland, MBA
Editor Elizabeth Moran, MSN, RN, CPNP-PC
COVID-19 prompted many states and healthcare systems to utilize Advanced Practice Providers (APPs) to the top of their licenses. By granting Full Practice Authority (FPA), physician oversight and monitoring was waived. APPs represent the collective group of Physician Assistants (PAs) and Advanced Practice Registered Nurses(APRNs), including Certified Registered Nurse Anesthetists (CRNAs) and Nurse Practitioners (NPs). Although some states allowed for independent APP practice prior to COVID-19, many did not. This swift shift was in response to increased staffing needs during surges.
APPs responded quickly to the demand for qualified providers to care for COVID-19 patients. For example, when Melnic advertised for help in New York, over 400 APP providers responded! Hospitals also witnessed as APPs filled important patient care roles. In many cases, APPs worked collaboratively with physicians, but without supervisory and other limitations. In other words, they practice to their full Scope of Practice. Now, as hospitals reassess their budgets due to the financial strain incurred by the pandemic, they are viewing APPs through a new lens. As healthcare systems consider bold and innovative moves towards efficiency, reduced costs, and high levels of quality care, APPs will be key players at the forefront of those conversations.
What is Scope of Practice and Full Practice Authority?
APPs who practice to their full Scope of Practice (SOP) work to the top of their license. Studies have shown this results in increased access to care, is shown to have good patient outcomes, and lowers healthcare costs. One example of eliminating physician oversight is allowing APPs to sign off on medications, orders, and charts independently. Rules governing FPA for NPs and PAs vary state by state. APPs are expected to provide the level of care that aligns with their SOP, institutional privileges, experience, and hospital bylaws. Learn more about the SOP for APPs in your state here.
What was the Impact of COVID on FPA for APPs?
During COVID-19, healthcare organizations needed to maximize the number of frontline providers able to care for patients during surges. As a result, most hospitals found it vital to utilize each profession to the top of their licenses. To increase access to providers during COVID-19, states and the U.S. Centers for Medicare & Medicaid Services (CMS) rapidly approved significant changes to supervisory, licensing, credentialing, and payments for APPs. According to the Health Affairs Blog, Emerging Health Workforce Strategies To Address COVID-19, “Strategies to maximize the current health workforce include licensing and enrollment flexibility, maximizing scope of practice, transitioning to ‘surge capacity’ staffing, telehealth, and redeploying health workers to high-need areas… We can see that during COVID-19 a number of Emergency Response Waivers are in place to enable healthcare organizations to utilize all trained frontline providers to build the teams necessary to handle patient surges.”
Scope of Practice and Full Practice Authority for APRNs
According to ANNP for Advanced Practice Registered Nurses (ARNPs), “Full Practice Authority state and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and the National Council of State Boards of Nursing.” Prior to COVID-19, 23 states had FPA for APPs. During the pandemic, 19 of the 30 states that previously did not have FPA have suspended or waived practice agreement requirements to allow for NP independence.
Scope of Practice and Full Practice Authority for PAs
According to AAPA, “Prior to the onset of the COVID-19 pandemic, numerous states were pursuing legislative changes to modernize PA practice. In 2019, North Dakota eliminated the requirement for a PA to have a written agreement with a physician to practice in most healthcare settings, and West Virginia eliminated the requirement that PAs who work in hospitals have practice agreements with specific physicians. In 2020, Maine removed the term supervision from state law and authorized a majority of PAs with more than 4,000 hours to practice without a written agreement. These efforts have gained momentum as states look at how best to respond to the current healthcare crisis. Twelve states have waived physician supervision requirements related to disasters and emergencies through prior legislation, while Maine, Michigan, New Jersey, New York, and Tennessee have waived physician supervision requirements for PAs through executive orders related to COVID-19, and more are expected to follow suit.” Currently, all but three states have a waiver in place for PAs.
What will happen to FPA after COVID-19?
A study piloted by Paula Brooks, D.N.P., M.B.A., FNP-BC, RNFA concluded: “Several recommendations were presented to department leaders about NP/CNM/CNS/PA practice. Departments that implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction,” .
Others echoed similar sentiments. “Greater uniformity would support health professionals’ ability to practice to the full extent of their education and training and enhance opportunities for efficient and effective health service delivery that better meets patients’ needs,” wrote Bianca Frogner, PhD, the director of Center for Health Workforce Studies at the University of Washington, and her seven colleagues.
Olga Jarrín, a registered nurse and assistant professor in nursing science at Rutgers University said, “One recent positive change to home care is allowing nurse practitioners and physician assistants to order home health care services for Medicare patients through the CARES Act.” According to Andrew Donvan of Home Health Care News,” the U.S. Centers for Medicare & Medicaid Services (CMS) is expected to allow non-physicians to certify home health services moving forward. The stimulus package specifically uses the framework of the April 2019 Home Health Care Planning Improvement Act, which sought to give nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) the ability to certify home health permanently.” He goes on to report that one of the benefits was,”On March 17, for example, CMS announced that home health providers could satisfy physician face-to-face requirements via telehealth technology — a first for the industry. Throughout March, CMS has issued roughly three dozen Medicaid 1135 waivers as well.”
Lev Facher of STAT news wrote about the impact of COVID-19 on healthcare. In his article, 9 ways Covid-19 may forever upend the U.S. healthcare industry, he predicts that hospitals will “allow non physicians, like nurses, nurse practitioners, and physician assistants to play a bigger role in care.”
Impact of Utilizing APPs to The Top of Their License
APPs utilized to the tops of their license contribute to high quality, efficient, and cost-effective healthcare. During this time of budget reevaluation, healthcare institutions are rethinking their costs, goals, desired outcomes, and capabilities of their staff. A clear understanding of each role, including what it means to work to one’s full scope of practice, is a vital element in this stage of pandemic reevaluation. Hospital administrators must collaborate with medical, APP, and nursing leads to identify the best path forward, including necessary changes to staffing models and innovative utilization of their human capital.
COVID-19 has been devastating for many reasons, but resilient healthcare industries can rebuild an efficient, cost-effective, high-quality environment. Melnic believes one key element is the utilization of APPs to the top of their license. Other healthcare providers, such as nurses, medical assistants, and certified nursing aids should also work to their full SOP. In fact, studies show that job satisfaction, recruitment, and retention is highest when an employee’s role matches their expectations and capabilities . With a pandemic peaking concern for burnout among health care workers, institutions must reckon with these factors to rain staff.
- Brooks, Paula B. DNP, FNP-BC, MBA, RNFA; Fulton, Megan E. MSPAS, PA-C Driving high-functioning clinical teams, Journal of the American Academy of Physician Assistants: June 2020 – Volume 33 – Issue 6 – p 1-12 doi: 10.1097/01.JAA.0000662400.04961.45
- Peng, Yuwen & Mao, Chao. (2014). The Impact of Person–Job Fit on Job Satisfaction: The Mediator Role of Self Efficacy. Social Indicators Research. 121. 805-813. 10.1007/s11205-014-0659-x.
To learn more about APP staffing, utilization, leadership, and retention strategies, please contact Jill Gilliland, President of Melnic. Jill@melnic.com
Jill Gilliland is President of Melnic an APRN and PA national recruiting company. Jill is a speaker and publicist on areas such as job strategies, branding and marketing, pediatric critical care needs, and additional topics relevant to pediatric nursing and the recruitment business. She has over 12 years of experience in the recruiting industry coupled with a strong sales, healthcare, and technology background. Jill holds a BS degree in Business from the University of Southern California and an MBA from The University of Virginia, Darden Business School. Connect with Jill Gilliland on LinkedIn.