Legislative victory: APN bills passed with overwhelming support!

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The Colorado Nurses Association is celebrating a sweet victory for Advanced Practice Nursing role and for improved access to care. Three bills sponsored by the Colorado Nurses Association were signed by Governor Ritter in March. A delegation of nursing representatives and members of AARP which also supported the bills were present for the bill signing. Legislative sponsors: Senator Bob Hagedorn, Representative Ellen Roberts, and Representative Sara Gagliardi also attended the event, and were instrumental in helping to move the legislation forward.

In summary, House Bill 1060 allows APNs to apply for participating provider status for a health benefit plan. Objective and reasonable criteria must be used to evaluate the application. If an APN is denied, specific reasons for the denial must be provided.

HB 1061 addressed the issue of signatures by APNs on specified documents within scope of practice. APNs will now have legislative authority to sign an affidavit, certification, or similar document within an established nurse-patient relationship, and within scope of practice that: document a patient's current health status, to authorize continuing treatment, tests, services, or equipment, that give advance directives for end of life care, and for parking privileges for persons with disabilities. Several older state statutes that reference requirement for physician signatures were updated to include authority for APN signature. Extensive discussions with the Colorado Medical Society and other physician specialty groups on the statutes helped to identify which statutes were mutually considered to be within scope of practice for an APN.

The Colorado Medical Society testified in support of HB 1061 at the Senate HHS hearing. Additionally, AARP, and the University of Colorado School of Medicine, and the University of Colorado Denver School of Nursing also supported the APN Bills. The support of professional colleagues on the bills has been gratifying and is duly appreciated.

HB 1094 updates the "Colorado Medical Assistance Act" language to authorize reimbursement for services for "advanced practice nurses." Previously there was only recognition for certified pediatric nurse practitioners or certified family nurse practitioners.

Testifying in support of the APN legislation for the Colorado Nurses Association were: Tay Kopanos, Marion Thornton, Marcia Gilbert, Barbara Hughes, Karen Tomky, and Fran Ricker.

The strength of the vote in support of these three bills in both the House and the Senate attest to legislators increasing awareness of access issues and the role of the Advanced Practice Nurse as a critical provider of care. Please note the vote record on the bills. In addition, many Co-sponsors signed on to support in both the House and Senate.

House Vote  Senate Vote
HB 1060-61  (Yes) to 1  34 (Yes) to 0
HB 1061-62  (Yes) to 0  34 (Yes) to 0
HB 1094-60  (Yes) to 2  34 (Yes) to 0

Fundamentals to Legislative Success--The Full Story

The body needs all parts to function with unity and precision to maintain optimal health. Successful legislative campaigns rely on similar principles to be successful. Just as bones, muscles and nerves must all work together for coordinated movement, so too must an organization with its strategy and message coordinate to move healthcare policy forward. By understanding and applying these principles, the Colorado Nurses Association has secured a victory for patients and nursing providers that will improve healthcare access, streamline care delivery and reduce redundancies in the system.

History of the APN bills:

Advanced Practice Nurses are key players in Colorado's healthcare system. We are on the forefront of health promotion, health maintenance and disease management. We are found in hospitals, offices, schools, correctional facilities and public health clinics across the state. However, there were statutes and legislative barriers that prevented APNs from providing services to patients even when their education and scope of practice had prepared them to do so. That is changing due to the unified efforts of Colorado's Advanced Practice Nurses and the Colorado Nurses Association.

The origin of these bills dates back several years. It started with Advanced Practice Nurses, like Karen Tomky and Karen Zink--both Nurse Practitioners in rural areas--sharing with CNA how their patients were encountering barriers in their practice settings that prevented healthcare access and care delivery even when that care was consistent with the APNs education and scope of practice. These were barriers like signing a handicap parking sticker, getting insurances to cover home health equipment, and patients having to seek primary care in an emergency room because a health insurance plan would not recognize primary care services from APNs. CNA heard these issues and looked for the "right opportunity" to bring them forward in the public policy arena.

In 2006, the opportunity came. Paula Stearns, MSN, RN, the immediate past Executive Director of CNA, and Charlie Hebeler, the CNA contracted lobbyist, were invited to participate in an interim task force on healthcare policy with legislators. During these meetings, they were able to share these barriers and propose ways to correct these issues for patients. Two days later, HB 07-1023 was sent to the legislative drafting office and the Advanced Practice community had its first piece of legislation since prescriptive authority.

The bill successfully passed the House of Representatives with a 64-1 vote. Unfortunately, Colorado House Bill 1023 was defeated in the Senate Health and Human Services committee.

Planning for 2008:

At the end of the session, the Government Affairs and Public Policy committee, Chaired by Tay Kopanos, met to discuss the legislation and explore the possibility of reintroducing the bill. The committee was unanimous in its decision to reintroduce these measures and set out to strategize ways to be successful in 2008. The strategy involved continued dialogues with physician groups and key stakeholders, clarification of our message, and a strong united consistent grassroots effort. Lobbyist, Charlie Hebeler, also guided working groups in an effective approach.

A Clear Consistent Message--The Muscle

The original bill was separated out into three separate areas-insurance empanelment, signature recognition, and update of Medicaid reimbursement language. Three separate bills were introduced as part of the strategy.

The message in dialogues on the bills was honed down to four key areas:

1. These bills are about improving the efficiency of the existing healthcare system by removing barriers that inhibit seamless and simplified care.

2. These bills are NOT about Scope of Practice Expansion! They are about removing operational barriers to practice.

3. These bills will expedite care for Colorado's patients in all areas of the state, not just the rural areas.

4. Over 4 decades of research support the safety, quality and cost-effectiveness of APN care. Many other states have already passed similar legislation to improve healthcare access and care delivery.

An extensive literature search was conducted by Marcia Gilbert, MSN APRN to identify the evidence basis for advanced practice nursing. Five volumes of carefully catalogued research evidence provided critical information on APN quality of care and safety. In testimony, Marcia was able to cite research studies supporting APN care.

Grassroots--The Nerves Connecting

The grassroots effort was championed by the APN nurses in Colorado who committed to supporting the legislative effort. A key district in implementing the grassroots plan was District 30-The Colorado Society of Advanced Practice Nurses, of the Colorado Nurses Association.

The campaign needed to develop a network of APNs that would be willing to speak directly with legislators on these issues. CNA, through the efforts of the Colorado Society of Advanced Practice Nurses (DNA 30), mailed letters to the 3500 APNs (both CNA members and non-members) in the state last fall seeking their support. Over 300 APNs responded. These individuals were integral to laying the foundation of success on these bills.

At critical times, APNs were emailed and asked to contact legislators in support of these bills, key messages were communicated, and details of actual patients that were negatively impacted by the current system were relayed. It was a tremendous success. During the testimony on the bills for the House Health and Human Services committee, many of the Representatives commented on the emails they had received from the APNs in support of the bills and even used them as a basis for questions when there was opposition brought on these bills.

DNA 31 has also been instrumental in dialogue on psychiatric related and mental health issues on the bills.

Dialogues with Physician Groups Colorado Nurses Association has committed extensive effort to continued dialogue with physician groups on Advanced Practice issues. Acknowledgment of the equal effort extended by the Colorado Medical Society to facilitate many discussions on the bills and issues is due.

The leadership members of both associations were committed to working on any issues and on coming to a point of agreement. The meetings enabled dialogue with the various physician specialty organizations which had varying points of view. Early meetings were at best challenging. Continued effort evolved into final meetings that were decidedly cooperative, supportive, and collegial. The working relationship that has evolved between the two professional disciplines will make it possible to work together on more complex and challenging health issues.

The main concerns of some of the physicians related to the following: patient safety, quality of care, understanding scope of practice for an APN, and clear understanding of regulatory oversight mechanism. There were opportunities in clarifying Board of Nursing role in relation to advanced practice nursing. Physicians also needed reassurance that APNs could identify appropriately when to refer to a physician and were practicing within their scope of practice.

After several meetings, nurses and physicians were each duly exuberant when agreement was reached on adding the following statement to the APN Registry section of the Nurse Practice Act: "An Advanced Practice Nurse shall practice in accordance with the standards of the appropriate national professional nursing organization and have a safe mechanism for consultation, or collaboration with a physician or, when appropriate, referral to a physician. Advanced Practice Nursing also includes, when appropriate, referral to other health care providers." Nurse midwives have had similar statutory language already in place.

One of the other key factors of the campaign was the tremendous depth of participation from the APN community to respond to issues that were raised by various stakeholders in the community. There were numerous articulate, experienced APNs to dialogue with constituent groups on the intent of the bills and on the educational preparation of APNs.

Input was provided by Charlie Hebeler, CNA Lobbyist, Barbara Hughes for Nurse Midwives, Cheryl Blankemeier for CRNA issues, Shirley McKenzie for Pediatric APNs, Eve Hoygaard, Sara Jarrett, Diane Dean, Mary Ciambelli, Karen Tomky for rural APNs, Josh Zucker DNA 30, Marion Thornton--DNA 30 President, Tay Kopanos, Maureen Doran for DNA 31--psychiatric APNs.... and many others. There was also support from other APNs and organizations in these dialogues. Many thanks to everyone who helped with this effort.

Additional thanks is extended to the following physicians and CMS staff for their efforts: Alfred Gilchrist, Dr. Lynn Parry, Dr. David Downs, Dr. Steve Lowenstein, Dr. Ben Vernon, Dr. Kent Voorhees, Dr. Sherri Laubach, Dr. Bruce Madison, Dr. Glenn Foust, Dr. Robert Brockman, Dr. Sue Townsend and Legal Counsel Kari Hershey.

Public Relations and Promoting APN Role--Circulation

A new project, the APN VIDEO, "Caring for Colorado" helped to promote our legislative agenda. The Colorado Nurses Association contracted with Sue Hagedorn, PhD, RN, NP and Vicki Erickson, PhD, RN, PNP from the University of Colorado Denver, School of Nursing to independently produce a video that portrays the various roles of Advanced Practice Nurses in providing care in Colorado. The video was also supported by the Colorado Society of Advanced Practice Nurses and by the Colorado Society of Nurse Anesthetists.

"A picture is worth a thousand words" Legislators on both Health and Human Services Committees were provided the video which detailed various APN roles and the multitude of settings APNs work in.

Tay Kopanos, DNP, FNP, RN & Fran Ricker, RN, MSN, CGRN