1. The Role of the ARNP:
What Does the Future
Hold
Julie Marfell, DNP, FNP,
BC, FAANP

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Introduction
Objectives:
Analysis the role of the ARNP in improving
access to primary care
Discuss the how health care reform will
effect the role of the ARNP
Discuss how ARNP’s can be utilized in a
public health setting

3. Mary Breckinridge, Founder
Frontier Nursing Service, 1925

4. Number of nurse practitioners
National
 158,000
Kentucky
 2,339
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5. Provider shortage
Predicted shortage of physicians in
2015 of 63,000. ( Association of
American Medical Colleges)
Health care reform will bring in
approximately 32 million Americans to
health insurance rolls.
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6. Provider shortage (continued)
108% increase in the number of nurse
practitioners from 2000-2009.
Kentucky 55 out of 120 counties HPSA
NP practice in 114 of our 120 counties
 43% of population live in rural areas
 28% of physician live in rural areas
27% shortage of Family Practice
Physicians
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7. To improve access to care all barriers must be
removed ARNP practice.
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8. Barriers to Practice
Prescribing barriers
36 states require written documentation of
physician involvement to prescribe (gold)
15 states and the District of Columbia have
no requirement for any physician
involvement (green)
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10. Some states still have a requirement for
physician involvement for diagnosing
and treating aspects of NP practice
23 states have no requirement for
physician involvement (green)
4 states have a requirement but do not
require written documentation (blue)
24 states require written documentation
(gold)
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12. Barriers to Practice
Reimbursement
In Kentucky
 Can be listed as a provider panels as a Primary
Care Provider
 Able to be reimbursed by 3rd
party payers and
HMO’s.
 Any willing provider
 85% reimbursement
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13. Consensus Model for APRN Regulation:
Licensure, Accreditation, Certification and
Education
2008 National Council of the State Boards of
Nursing
46 Nursing organizations endorsed the
Consensus Model
Addressed the fact that there is no uniform
model for regulation of APRN across the
states
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14. Consensus Model
APRN are unable to move easily from
state to state due to each state having
different criteria for licensure, this
decreases access to care
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15. Consensus Model
Defines APRN practice
Describes a regulatory model
Indentifies titles to by use
Defines specialties
Describes the emergence of new roles
and population foci
Provides strategies for implementation
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16. APRN Regulatory Model
Nurse
Anesthetist
Nurse
Midwife
Clinical Nurse
Specialist
Adult-
Gerontology
Women’s Health/
Gender Related
Family/Individual
Across lifespan
Neonatal Pediatrics
Psych/Mental
Health
Licensureatlevelsofroleand
populationfoci
POPULATION FOCI
APRN ROLES
APRN Specialties
Focus of Practice beyond role and population focus
Linked to health care needs
Examples include but are not limited to: Oncology, Older Adults,
Orthopedics, Nephrology, Palliative care, Critical Care
Nurse
Practitioner

17. APRN Titling
The title of Advanced Practice Registered
Nurse (APRN) is the licensing title to be
used for the subset of nurses prepared with
advanced, graduate-level nursing knowledge
to provide direct patient care in one of the
four roles.
Licensure is based on graduate education in
one of the four roles and population foci.
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18. APRN Titling (continued)
Verification of licensure will indicate the role
and population focus for which the APRN has
been licensed.
The nurse must legally represent themselves,
including in a legal signature, as an APRN
and by role (e.g. APRN-CNP)
The title of APRN and role titles are legally
protected titles and may not be used by any
individual who does not hold the proper
credentials.
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19. LACE: Regulatory Model
APRN regulation includes:
 Licensure
 The granting of authority to practice
 Accreditation
 Formal review and approval by a recognized agency of
educational degree or certification programs in nursing or
nursing related programs
 Certification
 The formal recognition of knowledge, skills and experience
demonstrated by the achievement of standards identified by the
profession
 Education
 The formal preparation of APRNs in graduate or post-graduate
programs
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20. Foundational Requirements for
Licensure
The Boards of Nursing (Licensure) will
 License APRNs in one of four roles with a population focus
 Be solely responsible for licensing (exception for states where
boards of midwifery regulate nurse-midwives and midwives)
 Only license graduates of accredited graduate programs
 Require successful completion of a national certification
examination that assesses APRN core, role and population
competencies.
 Only license an APRN when education and certification are
congruent
 Not issue a temporary license
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21. Foundational Requirements for
Licensure (cont.)
The Boards of Nursing will:
 License APRNs as independent practitioners with no
regulatory requirements for collaboration, direction or
supervision
 Have at least one APRN representative position on the board and
utilize an APRN advisory committee that includes representatives
of all four APRN roles
 Institute a grandfathering clause that will exempt those APRNs
already practicing in the state from new eligibility requirements
 Have the option for mutual recognition of advanced practice nursing
through the APRN Compact
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22. Foundational Requirements for
Accreditation of Education Programs
Accreditors will:
 Evaluate APRN graduate degree and post-graduate certification
programs
 Through their established accreditation standards and process,
assess APRN education programs in light of the APRN core, role
core and population core competencies
 Assess developing APRN education programs and tracks by
reviewing them using established accreditation standards and
granting pre-approval, pre-accreditation or accreditation prior to
student enrollment
 Include an APRN in the visiting team when reviewing an APRN
program
 Monitor the APRN education programs throughout the accreditation
period
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23. Foundational Requirements for
Certification
Certification programs providing APRN certification
used for licensure will:
 Follow established certification testing and psychometrically sound,
legally defensible standards for APRN examinations for licensure
 Assess the APRN core and role competencies across at least one
population focus of practice
 Assess specialty competencies separately from the APRN core,
role and population focused competencies.
 Be accredited by a national certification accreditation body
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24. Foundational Requirements for
Certification (cont.)
Certification programs providing APRN certification
used for licensure will:
 Enforce congruence between the education program and the type
of certification examination
 Provide a mechanism to ensure ongoing competence and
maintenance of certification
 Participate in ongoing relationship which make their processes
transparent to BON
 Participate in a mutually agreeable mechanism to ensure
communication with the BON
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25. Foundational Requirements for
Education
APRN educational programs/tracks leading to
eligibility for a APRN license will:
 Follow established educational standards and ensure attainment of
the APRN core, role core and population core competencies
 Be accredited by a nursing accrediting organization that is
recognized by the U.S. Department of Education and/or the Council
for Higher Education Accreditation
 Be pre-approved, pre-accredited, or accredited prior to the
acceptance of students, including all developing APRN education
programs and tracks
 Ensure that graduates of the program are eligible for national
certification and state licensure
 Ensure that official documentation (e.g. transcripts) specifies the
role and population focus of the graduate
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26. Future of Nursing: Leading Change,
Advancing Health
Report done by the Institute of Medicine
(IOM) and Robert Wood Johnson
Foundation (RWJ)
Published in October, 2010
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27. Recommendations
Remove regulatory barriers to nursing
practice
Raise the education level of the nursing
workforce
Enhance nursing’s leadership role in
health care redesign
Strengthen data collection efforts
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28. Key Messages
Nurse should practice to the full extent
of their education and training
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29. Key Messages (continued)
Nurses should achieve higher levels of
education and training through an
improved education system that
promotes seamless academic
progression.
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30. Key Messages (continued)
Nurses should be full partners, with
physician and other healthcare
professional, in redesigning healthcare
in the United States.
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31. Key Messages (continued)
Effective workforce planning and policy
making require better data collection
and improved information infrastructure.
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32. Action steps
Increase the number of nurses with
baccalaureate degrees from 50% to
80% by 2020.
Encourage nurses with associate degrees
and diplomas to enter baccalaureate
programs within five years of graduation.
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33. Action steps (continued)
Double the number of nurse with
doctorates by 2020
Currently 10% of nurses hold doctorates
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34. Action steps (continued)
Address the faculty shortage by
creating competitive salary and benefit
packages
Average academic salary:
Average family nurse practitioner:
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35. Action steps (continued)
Encourage 10% of baccalaureate
program graduates to enter master’s or
doctoral programs within 5 years of
graduation
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36. Action steps (continued)
Remove practice barriers that inhibit
APRN from practicing to the full extent
of their education and training and
serving in primary care roles
Kentucky Coalition of Nurse Practitioners
and Nurse Midwives
 http://www.kcnpnm.org/
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37. Action steps (continued)
Enhance new nurse retention by
implementing transition into practice
nurse residency programs
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38. Action steps (continued)
Embedding leadership development in
to nursing education programs and
increasing the emphasis on
interdisciplinary education.
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39. Action steps (continued)
Ensuring nurses engage in lifelong
learning to gain the competencies
needed to provide care for diverse
populations across the lifespan.
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40. Innovated models of care
Patient –Centered Medical Homes
Primary care that is focused on
providing customized services for each
patient that reflects individual preferences.
Information is provided at the point of care
and focus is changed from visits to care
over time.
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41. Patient –Centered Medical Homes
(continued)
National Committee on Quality
Assurance (NCQA) will recognize
nurse-led primary care practices as
patient centered medical homes.
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42. Innovated Models of Care
Programs that support preventative
services
Good care in modest cabins
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43. Nurse practitioner owned health
care practices
Collaborative agreement is a barrier
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44. Doctor of Nursing Practice
Currently there are 37 programs
nationwide offering the DNP.
92 more lined up for accreditation
Unsure if 2015 will be actualized, possible
2020.
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45. Quality of Nurse Practitioner Care
National Provider Data Bank
Malpractice reports (1999-2009)
 National data
 NP 1:166 reports
 DO 1:4
 MD 1:4
 Kentucky
 NP 1:213 reports
 DO 1:8
 MD 1:4
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46. Quality of Nurse Practitioner Care
(continued)
Health Care Integrity and Protection Databank
 Accumulated adverse reactions (1999-2009)
 National data
 NP 1:215 reports
 DO 1:14
 MD 1:20
 Kentucky data
 NP 1:234 reports
 DO 1:10
 MD 1:14
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47. Conclusions
Nurse practitioners are increasing
access to primary care
Nurse practitioners are provide safe
health care.
Nursing and nurse practitioners are
poised to be one of the solutions to our
healthcare crisis.
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48. Ride the wave
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49. References
APRN Consensus Work Group & the National Council of
State Boards of Nursing APRN Advisory Committee (2008)
Consensus Model for APRN Regulation: Licensure,
Accreditation, Certification & Education
http://www.aacn.nche.edu/education/pdf/APRNReport.pdf
Center for Workforce Studies Association of American Medical
Colleges (2009) Recent Studies and Reports on Physician
Shortages in the U.S.
http://www.aamc.org/workforce/stateandspecialty/recentworkfor
cestudiesnov09.pdf
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50. References (continued)
Kentucky Coalition of Nurse Practitioners and Nurse-Midwives
(2009) Nurse Practitioners and Nurse Midwives Provide Quality,
Cost Effective Care but Barriers to their Practice Decrease
Patient Access to Care.
http://www.kcnpnm.org/resource/resmgr/white_papers/kcnpnm_
white_paper_9.20.10.pdf
National Committee on Quality Assurance (2010) Recognizing
Nurse Led Practices of Patient-Centered Medical Home.
http://www.ncqa.org/
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51. References (continued)
National Council of State Boards of Nursing (ND)
Consensus Model for APRN Regulation: Licensure,
Accreditation, Certification, Education ,
https://www.ncsbn.org/APRN_Consensus_Model_PowerPo
int_Presentation.pdf
Pearson, Linda (2010) The Pearson Report: A National
Overview of Nurse practitioner Legislation and Healthcare
Issues. http://www.pearsonreport.com/
Institute of Medicine(2010) The Future of Nursing: Leading
Change, Advancing Health.
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-
Leading-Change-Advancing-Health.aspx
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For More Information about the
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