Acknowledgements TheBCNPAwouldliketoacknowledgethesupportandcontributionsofnumerouscolleagueswhotookthetimetooffertheirvaluableinsight,expertiseandfeedbackforthisdiscussionpaper.

LeadAuthors:• Dr.NatashaProdan-Bhalla,BScN,MN,NP(A),DNP• LorineScott,BSN,MN,NP(F)

ContributingAuthors:• MichelleBech,BSN,MN,ACNP,NP(A)• LeahChristoff,MSN,NP(F)• Belinda-AnnFurlan,MSN,NP(F)• KathleenFyvie,BSN,ENC(C),MN,NP(F)• CarolGalte,MN,NP(Retired)• AnnalieseHasler,BScN,NP(F)• FionaHutchison,BSN,MSN,NP(F)• JessicaLePage,RN,BSN,MN,NP(F)• KathyLepp,MN,NP(F)• Dr.MinnaMiller,DNP,MSN,NP(F),FAANP• CarrieMurphy,MN,NP(F)• SuePeck,BSN,MSN,NP(F)• BarbRadons,MN,NP(F)• KarenSims,BScN,MN-ACNP,NP(A)• JenWatters,MN,NP(A)

GraphicDesign/Layout:• MichaelHarrison

Editors:• TiffanyBarker,RN• AndreaBurton,MA

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Executive Summary Inover60countriesworldwide,NursePractitioners(NPs)increaseaccessinspecialty1careandimprovebothpatientandsystemoutcomesacrossthecontinuumofcare.NPsinspecialtysettings-acute,ambulatory,andresidential-havedemonstratednotonlyimprovedpatienthealthoutcomesandcontinuityofcare,butalsoimprovementsinteamfunctioningandresourceutilization(AANP,2016;Hiza,Gottschalk,Umpierrez,Bush&Reisman,2015;Collinsetal.,2014;Kapu,Kleinpell&Pilon,2014;Watters,Aaronson,Sobolyeva,&Galte,2014;AANP,2013;Forster,2012;Goldie,Prodan-Bhalla,&MacKay,2012;Fry,2011;&Kilpatricketal.,2010).Despitethis,broadutilizationoftheseNPclinicalleadersinspecialtysettingsinBritishColumbia(B.C.)hasbeenhamperedbynumerousbarriersincludinginconsistentimplementationprocesses,alackofunderstandingand/oravailabilityofspecialtyeducationrequirements,roleclarityissuesandafocusonutilizingNPstostrengthenthedeliveryofprimarycareratherthanspecialtycare(Sangster-Gormley,2012;Bauer,2010).

SpecializedServices:NursePractitionersCollaboratingtoImprovetheContinuumofCareandtheaccompanyingToolkitarecompaniondocumentstoPrimaryCareTransformationinBC:ANewModeltoIntegrateNursePractitioners(BCNPA,2016).ThispaperoutlinesrecommendationsforoptimizingandsustainingexistingNProlesinspecialtycaresettings,andprovidesguidanceforthedevelopmentofaprovincialstrategytotakefulladvantageoftheNPproviderclinicalskillsetandexpertiseinadvancednursingleadership,transitionalcare,andtransformationalpolicydevelopment.NPsprovidecomprehensivecaretopatientswhileinhospital,incorporatinghealthpromotionandpreventionandhealthmanagementcareinrelationtospecificdiseases/chronicconditions.Thisapproachisshowntoimprovecoordinationofappropriatedischargeplanningandtocollaborativelyfacilitatefollow-upcarewithcommunityproviders–ineffectenactinganoftenunrecognizedbutimportanttransitionalmodelofcarethroughthepromotionofadynamicandresponsivemodeofhealthcaredeliveryforthepatient(Bryant-Lukosiusetal.,2016).

TheBritishColumbiaNursePractitionerAssociation(BCNPA)agreeswithandsupportstheMinistryofHealth’s(MOH)emphasisandfocusonpromotingtheintegrationofNPstoimproveaccesstoprimarycareforallBritishColumbians.However,healthcareprovisionhasbecomeincreasinglychallengingaspatientstodayarelivinglongerwithchronic,oftencomplexdiseasesandarefrequentlymovinginandoutofspecializedprogramsastheirhealthstatuschanges.NursePractitionersareexpertsatseamlessandsafetransitionsacrosshealthcareservicesandsettingsalongthecarecontinuumandareintegraltoensuringoptimumpatientexperiencesandarobustandeffectivehealthcaresysteminallsectors.

Today,approximately40percentofNPsinB.C.provideservicesinspecializedsettingsasoutlinedinTable1.Thisisasurprisinglylargenumberconsideringtheprovincialstrategyforimplementationsince2005hasfocusedonutilizingNPstoincreaseaccesstoprimarycare.TheinterestinNPprovidersandemploymentopportunitiesforNPsinspecializedroleshascontinuedtogrow,despitelogisticalchallenges.GiventhenumberofcreativeandresponsiveNProlesinspecialtysettingscurrentlydemonstratingmeaningfuloutcomes,thereisanimpetustoconsiderimprovedwaystostrategicallyplanforandsupportamoredeliberateandstructuredimplementationofNPsinthesesettingsasacomplementtotheircolleaguesinprimarycare.

B.C.hasanopportunitytodeploymoreNPsintoprimarycaresettingsunderanewstrategyasoutlinedinPrimaryCareTransformationinBC:ANewModeltoIntegrateNursePractitioners(BCNPA,2016),whilealsofullyutilizingNPsinspecialtycare,therebyincreasingaccesstocareacrossthehealthcarecontinuum.The______________________________________________________________________________________________1Forthepurposesofthispaper,thetermspecialtywillbeusedtodescribeNPsworkinginAcute,AmbulatoryandResidentialsettingsprovidingsecondary,tertiaryandquaternarycareasopposedtoPrimaryCaresettings.

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BCNPAagreeswithandsupportstheMOHtripleaimsofimprovedhealthcareoutcomes,improvedpatient/providerexperienceandefficientcost-effectivecareasoutlinedinthe2016ServicePlan(B.C.MOH,2016).Thisincludesafocusonmultidisciplinaryteams,collaborativepracticeandcarethatisdevelopedwithand‘wrappedaround’thepatient.IncorporatedwithinthisdiscussionpaperarefundamentalprinciplestoensuresuccessfulNPimplementation/integrationthroughoutspecialtycarethatwillplacetheNPworkforceinastrongpositiontosupportteambasedcareandtheMOH’sgoalswithinarevitalized,coordinatedhealthcaresystem.

Withthisdiscussionpaper,theBCNPAhasprovidedinnovativecollaborativesolutionsandthefoundationalelementsrequiredtoaddressthepersistentbarrierstoeffectiveNPimplementation/integrationinspecialtysettings,andrecommendsthedevelopmentofarobustprovincialvisionandstrategy.TheBCNPArecommendstheMOHworkwiththeHealthAuthority(HA)-ChiefNursingOfficers(CNO),theHA-NPLeads,theCollegeofRegisteredNursesofBritishColumbia(CRNBC),theNursesandNursePractitionersofBC(NNPBC),theMinistryofAdvancedEducationandSkillsDevelopmentandotherkeystakeholderstodevelopasustainablestrategythatwillsupportcomplementaryandalternativerolesforNPswithinspecializedinterdisciplinaryteamswithinbothcommunityandacutecaresystems,suchthatthereisaclearvisionforeffectiveNProlesnow,andinthefuture.

KeyRecommendations1. DevelopaSustainableSalary-BasedNPFundingFramework

2. Develop,AdoptandImplementaQualityAssuranceFramework

3. DevelopaWorkingGrouptoReviewandUpdateNPRemuneration

4. DevelopaHealthHumanResourcesStrategytoNPDeployment

5. EmployNPsandIncreaseEducationalSeatsAccordingtotheHealthHumanResourcesStrategy

6. ReviewandUpdateNPEducationinB.C.toReflectPopulationNeeds

7. DevelopNPPostgraduateFellowshipPrograms

8. AdoptaNPProfessionalPracticeFrameworktoEnableaStandardizedApproach

9. DevelopandImplementanNPRoleClarityCampaign

10. RemoveLegislative,RegulatoryandOrganizationalBarriers

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Key Messages

• Avision,basedonpopulationhealthneeds,isrequiredforallNProlesinspecialtysettings.

• Approximately40percentofNPsworkinginBritishColumbiaarepracticinginspecialtyroles.

• NPsareanunderutilizedprovidergroupthatcansupportincreasedaccesstohighqualityspecializedcareforBritishColumbiansbysupportingtheMOHTripleAimgoals-“improveoutcomes,enhancepatientexperienceandreducecosts.”

• HealthcareisacontinuumandNPshaveenormousimpactwhentheyareenabledtoprovideseamlesstransitionsacrossthatcontinuumandbetweensectors.

• NProlesinspecialtysettingscontributetopositivehealthoutcomes,improvingtheresponsivenessandfunctionofinterdisciplinaryteamsandcomplementexistingphysicianandnursingroles.

• Transformingthecurrenthealthcaresystemtoachievethetripleaimsshouldfocusonmodelsthatarepatient-centred,interdisciplinaryandcollaborative,andappropriatelyutilizetheskillsofallprovidersincludingtheNP.

• ArobuststandardizedframeworkandstrategyforNPimplementationinallroles,includingspecializedpractice,isessentialforthesustainabilityoftheNProleinB.C.

• PolicymakersmustimplementanappropriatefundingmodelforallNPsworkinginB.C.(AfulldiscussionofthismodelcanbefoundintheBCNPADiscussionPaper:PrimaryCareTransformationinBritishColumbia:ANewModeltoIntegrateNursePractitioners,2016).

• FundingmodelsmustrecognizethevalueofthefullpackageofservicesthattheNProlebringstoateam.

• NPremunerationmustrecognizeandreflecttheeducationalpreparation,scopeofpracticeandtheNPsroleasclinicalleaderswithautonomousresponsibilityforpatientcare.

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Table of Contents

Acknowledgements......................................................................................................................................2LeadAuthors:................................................................................................................................................2Editors:..........................................................................................................................................................2

ExecutiveSummary......................................................................................................................................3KeyRecommendations.................................................................................................................................4

KeyMessages...............................................................................................................................................5

Introduction.................................................................................................................................................8

Background................................................................................................................................................10

UnderstandingSpecialtyRolesinB.C.........................................................................................................13AcuteCare...................................................................................................................................................14AmbulatoryCare.........................................................................................................................................15ResidentialCare...........................................................................................................................................16

ClarifyingSystemChallenges......................................................................................................................18StepsTowardaStrategyforNPsWorkinginSpecialtySettings................................................................18ClarifyingSystemPriorities.........................................................................................................................18LackofaSustainableFunding&RemunerationModel.............................................................................19

1.Recommendation:DevelopaSustainableSalary-basedFundingFramework...................................20LackofaQualityAssuranceFramework.....................................................................................................20

2.Recommendation:Develop,AdoptandImplementQualityAssuranceFramework..........................22Out-DatedNPRemuneration......................................................................................................................22

3.Recommendation:DevelopaWorkingGrouptoReviewandUpdateNPRemuneration..................23LackofaHealthHumanResourcesStrategy..............................................................................................24

4.Recommendation:DevelopaHHRStrategytoNPDeployment.........................................................255.Recommendation:EmployNPsandIncreaseEducationalSeatsAccordingtotheHHRStrategy.....25

NPEducationalProgramsNotReflectiveofEmploymentOpportunities..................................................276.Recommendation:ReviewandUpdateEducationinB.C.toReflectPopulationNeeds.....................28

LackofPostgraduateNPEducation............................................................................................................297.Recommendation:DevelopNPPostgraduateFellowshipPrograms..................................................29

LackofaStandardizedProfessionalPracticeFramework..........................................................................308.Recommendation:AdoptaProfessionalPracticeFrameworktoEnableaStandardizedApproach.30

PersistingIssueswithRoleClarity...............................................................................................................319.Recommendation:DevelopandImplementanNPRoleClarityCampaign........................................32

Legislative,RegulatoryandOrganizationalRestrictionstoNPPractice.....................................................3310.Recommendation:RemoveLegislative,RegulatoryandOrganizationalBarriers...........................33

GuidingPrinciples.......................................................................................................................................34Patient-Centred...........................................................................................................................................34InterdisciplinaryandCollaborative.............................................................................................................34NPRepresentation......................................................................................................................................35

SummaryofRecommendations.................................................................................................................36

Summary....................................................................................................................................................37

GlossaryofTerms.......................................................................................................................................38

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AppendixA–NPFundingOptions..............................................................................................................41OptionA-HAEmployed.............................................................................................................................41

AppendixB.................................................................................................................................................42OptionB-HAAffiliated...............................................................................................................................42

AppendixC–EstimatedBudget.................................................................................................................43

AppendixD–QualityAssuranceFramework-Example..............................................................................44

AppendixE–CaseStudy............................................................................................................................45OptionA:HAEmployed..............................................................................................................................45

AppendixF–CaseStudy............................................................................................................................46OptionB:HAAffiliated................................................................................................................................46

References.................................................................................................................................................47

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Introduction NursePractitionersinBritishColumbiacanbefoundacrossthehealthcaresystemtodayinavarietyofrolesinacute,ambulatory,andresidentialcareatsecondary,tertiaryandquaternarylevelsofcareacrossallHealthAuthorities.Inaddition,therearealsoNPsinB.C.workinginindustryandthenon-profitsector.TheserolesplacetheNPoutsideofprimarycare,caringforpatientpopulationswithspecializeddiseases/conditions/needswhohaveincreasinglevelsofcomplexity,suchaspatientslivingwithmentalillness,substanceusedisorder,chronicdisease,andcanceralongwithpopulationswhoaremarginalizedandvulnerable.NProlesoutsideofprimarycaresupportseveralofthegoalslaidoutintheSettingPrioritiesfortheB.C.HealthSystem(B.C.MOH,2014b)policypapers,andshouldbebetterunderstoodandutilizedtosupporttheMOHgoalsandobjectives.NPsinspecialtycareareworkingincomplementaryroles,enhancingtheexistinginterdisciplinaryteammodelandimprovingteamfunctioning.ManyoftheseNPsbringextensiveadvancedpracticespecialtyorsub-specialtyknowledgeandexpertisethatsupportsandaugmentstheexistingcaremodel,increases/improvesaccesstospecialtycare,improvestheacutecaretrajectoryandthepatientexperienceofcarereceivedandfostersseamlesstransitionsbackintothecommunity.AddressingsystempressuresinspecialtycarethroughtheutilizationoftheNPworkforcerequiresthoughtfulplanningandcollaborationamongallstakeholdersincludinggovernment,healthauthorities,academicprograms,NPs,physiciansandothermembersofthehealthcareteam.DespitetheconsiderableworkcompletedrelatedtohealthcarereformandtheimplementationofNPsinBritishColumbiasince2005,severalbarrierstofullutilizationoftheNProlepersist.FocusingNPfundingonprimarycaredeliveryhasdeniedthechallengesandtransitionsthatpatientswithcomplexhealthissuesfaceanddoesnotenableaseamlesssystemofcare.Thesiloeddivisionsbetweenprimary,secondary,tertiaryandquaternarycarehasbecomearbitraryandisnotreflectiveoftoday’shealthcarecontinuum,whichisreflectedinanobjectiverestatedinthe2015PrimaryandCommunityHealthpolicydocumenttosupportseniorstoremainindependentandathomeforaslongaspossible(B.C.MOH,2015a).In2006,theCanadianNursePractitionerInitiative(CNPI)publishedareportwith13recommendationsforsustainableimplementationoftheNPinCanada.Sincethattime,thenumberofNPsinthecountryhasgrownby300percentindicatingthatNPsareinhighdemand(CNPI,2016).TheCNPI:A10YearRetrospectiverecognizesthenumerousimprovementsthathavebeenachievedoverthelastdecadeincludingtitleprotection,andacommonroledescription(CNPI,2016).However,italsohighlightstheneedforfurtherworkinsustainablefundingstrategies,removinglegislativebarrierstopractice,expandingteam-basedmodelsthatincludeNPs,anddevelopingastandardapproachtohealthhumanresourcesplanningandrecruitment(CNPI,2016).

Canadian NP Context (CNA, 2017)

• Approximately4,500NPsarecurrentlypracticinginCanadao 35%ofCanadianNPsworkinprimarycare

o 40%ofCanadianNPsworkinspecialtysettings

o 3%ofCanadianNPsworkinresidentialcare

British Columbia NP Context (BCNPA, 2017)

• Approximately402NPsarecurrentlypracticinginB.C.o 60%workinprimarycare(50%workwithspecializedpopulations)

o 40%workinspecialtysettings

GuidingPrinciples

PatientCentred

Interprofessional

NPRepresentation

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ThebarriersoutlinedinTheCNPI:A10YearRetrospective(CNPI,2016)arecertainlyreflectedintheB.C.context.Inaddition,NPsinB.ChavefaceduniquebarrierstopracticeincludingadisconnectbetweenNPeducationalprogramsandemploymentsettings,andevenmoredetrimentally,alackofaclearvisionandplanfortheimplementationoftheNProleinbothprimaryandspecialtysettings.ThisdocumentoutlinesasetofrecommendationstoensurearobustsustainableplanforexistingNProlesinspecialtycaresettings,andsetsthestageforthedevelopmentofaviableprovincialstrategyandvisionasstakeholdersanticipatethefutureandmoveforwardwithNPsinspecialtycare.BCNPArecognizesthattherecommendationsoutlinedinPrimaryCareTransformationinBritishColumbia:ANewModeltoIntegrateNursePractitioners(BCNPA,2016)areapriorityhowever,ashealthcareplanningisnotstagnant,therecommendationsoutlinedinthisdiscussionpaperarecomplementaryandpromotearesponsive,robust,fulsomehealthcaresystem.

CameraVanBreeman,NP(F),PediatricPalliativeCare,NonProfitSector-Vancouver,B.C.“Asamemberoftheinterdisciplinaryteamofprofessionals–physicians,registerednurses,careaids,socialworkers,counsellors,spiritualcare,expressiveandrecreationaltherapists,Iprovidein-personconsultationsatthehospice,outpatientclinics,in-patientunits,andprovidehomevisitsinthelowermainland.Visitstootherpediatricwards,communityagenciesandtochildren’shomesoutsidethelowermainlandarealsoavailablesothatcareplanningandassessmentcanbedoneifthechild/family’swishistodieintheirhomecommunity.Iprovidetreatmentandcarerelatedtocomplexsymptommanagement,careplanning,advanceddirectivesandcarecoordinationacrosssettings.Inaddition,inmyNProleIprovidepediatricpalliativecareeducationandconsultativesupporttohealthcareproviderssuchaspediatricians,generalproviders,nursingsupportservicesandcontractednursingservices.Thistranslationofspecializedknowledgerelatedtopediatricpalliativecareisnecessarytoensurethatchildrenandfamiliesreceiveappropriatecare.”

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Background EconomicanalyseshavedemonstratedthatwhenNPsworkautonomouslyinavarietyofclinicalsettingstheentirehealthcaresystemisreformed(Bauer,2010).ThepopulationisaginginB.C.,thedemandforskilledmedicalpractitionersinacutecareisontheriseandtheeconomicbenefitoftheNProleinspecialtysettingsiswellestablished(RNAO,2015;Kapu,Kleinpell&Pilon,2014).NPsareprimaryfacilitatorsinimprovingcommunicationbetweenspecialtycareandprimarycareleadingtosignificantimprovementsincontinuity,carecoordinationandtransitionsacrossthespectrumofservicesneeded.

StudieshaveshownthatthespecializedNProleiscosteffective,particularlyindecreasinglengthofstay,andensuringtimelydischarge,whichindirectlydecreaseshospitalcosts(RNAO,2015;Kapu,Kleinpell&Pilon,2014).DecreasedhospitalcostshavealsobeenreportedduetocostsavingssecondarytotheutilizationoffewerresourcesbyNPs(Jennings,Clifford,Fox,O’Connell&Gardner,2015;McDonnelletal.,2015;Kleinpell,2005).Multi-disciplinaryandinterprofessionalteamsthatincludeNPshaveimprovedpatientoutcomes,improvedpatientexperience,improvedprovidersatisfaction/teamfunctioning,increasedcoordinationandarecostefficient(Lietal.,2017;Hiza,Gottschalk,Umpierrez,Bush&Reisman,2015;Jennings,Clifford,Fox,O’Connell&Gardner,2015;McDonnelletal.,2015;Kapu,Kleinpell&Pilon,2014;Collinsetal.,2014;Fry,2011;Kilpatricketal.,2010;).McDonnelletal.,(2015),demonstratedthatNPsworkinginacutecarealsocontributetotheachievementoforganizationalpriorities,targetsandpolicydevelopment.

ThereisanewfrontierinhealthcareinBC;onethatemphasizestheneedforpatientstostayintheirhomesandcommunitieslonger,ratherthaninhospital,oftenresultinginfurtherillnessandreadmission(Lax&Gilbert,2015).NursePractitionersworkinginspecializedsettingsarewellpositionedtoworkincollaborationwithprofessionalsinprimarycaresettingstoensuresmoothtransitionsacrossthespectrumofhealthcarefromhometocommunity,acutecare,ambulatory,residential,palliative,andmoreasoutlinedinFigure1.NPsaremobile,agileandadaptivetomeettheneedsofthepopulationashealthcareneedsandsystemschange.ThebroadskillsetoftheNPincludesexpertiseinclinicalcare,organizationalleadership,policydevelopment,andchangemanagement,whichprovidesastrongfoundationfornavigatingcomplexsystemsandcomplexpatientneeds.WhethertheNPisprovidingservicesincardiacsurgery,orthopedics,trauma,orcancercare,theroleoftheNPensureshighquality,efficientcarethatprovidesasmoothtransitionbackintothecommunity(CNA,2016;Martin-Miseneretal.,2015).

MichelleBech,NP(A),Orthopedics-Surgical-Vancouver,B.C.“AsamemberoftheOrthopedicmulti-disciplinaryteamsince2005,Iwashiredtocomplementtheexistingteamstructure,Iamresponsibleforthecareoffracturepatientsfromadmissionàpre-opàpost-opàoutpatientfollow-up.SinceaddingtheNPtothisspecializedteam17yearsago,ongoingresearchhascontinuedtodemonstratethismodelisyieldingasignificantdecreaseinlengthofstayforhipfracturepatientsbyover30days.

Ourprogramrecentlyreceivedexemplarystatus(AmericanCollegeofSurgeonsNationalSurgicalQualityImprovementProgram,2017),placinginthetop10percentof300-400bedteachinghospitals,demonstratinglowratesintheareasofVenousThromboembolism,readmissions,returntoORandmortality.Theconsensusisthatthe“NProlehasaddedtotheeffectivenessofthissurgicalteamandispositivelycontributingtotheongoingimprovedoutcomesforsurgicalpatients”.

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NPRoleinSpecialtyCare:AFullPackageofServices

• Worksasmemberofaninterdisciplinaryteam,complementingotherteammemberroles.

• Bringsaholisticnursingsciencelens(specializedknowledge,skills/experience)tomedicalcareexpandingtheinterventionsavailabletopatients.

• Providesindependentevidenceinformedassessment/clinicalpracticeconsultation&carecoordinationpre-admission,duringadmission&postdischargeasoutlinedinFigure2.

• Collaborateswithpatient/family,interdisciplinaryteamandothersupportsystemsduringadmissioncoordinatingdischargeplanningneedsincludingsupportrequiredathome

• Considersprimarycareneedsincludinghealthpromotionanddiseasepreventionwhilefocusingonspecializedillness.

• Maintainsafocusontransitionsbetweensectorsofthehealthcaresystemandkeepingpatientsoutofhospital

• Actsaspointofcontacttofacilitatecommunicationacrosssystemsectorsincludingspecialtycareàprimarycareàcommunity/homecare.

• Identifiesservicegaps&strategiestoimproveteamcareandfunctioningworkingtoensureteamresponsiveness.

Bringingaholisticnursingsciencelenstopractice,specializedNPsconsidertheprimaryhealthcareneedsofpatientswhilethepatientisinanacutecaresetting.Forexample,anNPworkingininpatientmentalhealthwillidentifyvulnerabilitiessuchasengaginginhigh-risksexualbehavioursoridentifyingriskfactorsforheartdiseaseandensuringappropriatescreeningandhealthpromotioninterventionsareundertakenorthehealthconditionisalsoaddressedwhileinhospital,issuesthatapsychiatrist,oraddictionsmedicinephysicianmaynotincludeaspartoftheirpractice.AnNPworkingintheemergencyroomwilldiscusspreventionandhealthpromotionstrategieswithpatientstokeepthemfromreturningtotheEDforroutinecareandanNPworkingintraumawillsupportthepatientfromthetimeofinjury,throughouttheacutehospitalstay

andensureanappropriatedischargeandtransition,providingthepatient/familywiththeeducationtheyrequiretomanagetheirhealthissuesbackintothecommunity.

Disappointingly,despiteeffortstodate,NPscontinuetofacechallengesinfullyintegratingintothebroadersystemandsignificantbarrierstoNPpracticeremain.A2012surveyofNPsworkinginB.C.foundmanyemployedNPsexperienceproblemsworkingtofullscopeofpracticeduetopersistinglegislativebarriersandrestrictiveorganizationalstructures.Someotherbarriersidentifiedincludedlackofplanning,roleclarity,arestrictivesalarymodelthatdoesnotacknowledgethescopeofclinicalNPcare,andlackofphysicianandadministrativesupport(Contandriopoulosetal.,2015,Sangster-Gormley,2012).ItistimetodevelopastrategywithaclearvisionandimplementationplantoremovethesebarriersforNPsdeliveringbothprimaryandspecializedcare.

StevenHashimoto,NP(F),MentalHealth–Burnaby,B.C.ImprovingTransitions:Iworkatalargein-patientfacilitythatprovidespsychiatrictreatmentandaddictionmanagementtoadults(19+)whohaveconcurrentdisorders(includingbothpsychiatricandaddictionissues).Asamemberofthemulti-disciplinarymentalhealthteam,Iprovidetheneededprimarycareservicesforclientswhiletheyareadmitted,managingmultipleacuteaswellaschronicconditionssuchascellulitis,STIs,hepatitisC,COPD,diabetesanditscomplicationsinthepresenceofthesubstanceusedisorder.Addictionmedicinecareisprimarilyaresponsibilityforgeneralpractitioners(GPs)ontheteam,howevertheNPprovideslocumcoverageandmanagesacutewithdrawalsymptomsfromalcoholoropioidsandcontinuestoprescribeopioidsfornon-cancerchronicpainandSuboxoneasapartofaddictiontreatment.”

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Figure1.NursePractitionersasMembersofInterdisciplinaryTeams.BCNPA(2017).PleaseNote:TheNPwillbeworkingwithininterdisciplinaryteamsatallofthesetransitionpoints

13

Understanding Specialty Roles in B.C. ManyNPspracticinginB.C.todayaremembersofhighlyspecializedmulti-disciplinaryteamssuchascardiology,nephrology,trauma,haematologyandoncologyandareprovidingcareinacutecarehospitalunits,specialtyambulatorycareprogramsandresidentialcaresettingsinprogramsservingadults,seniors,children/youthandneonates.Asdescribedabove,NPsasmembersofspecializedteams,aremostoftencomplementingotherproviderroleswithinexistingteambasedmodelsofcareaddingvaluetotheexistinginterdisciplinaryteambypositivelycontributingtoimprovingaccesstospecialtycare,facilitatingconnectionsacrosssectorsandimprovingpatienthealthoutcomes,teamfunctioningandresponsiveness.Morerecently,therearesomeexamplesinBCofNPsworkingasanalternativeprovidertoaMD.Theseroleshavebeenimplementedwhereappropriate,toaddressspecificpopulationneedsandasonestrategytoaddressprovidershortages.Inallsituations,NPsareprovingtobringvaluetothepatient/family,thehealthcareteamandthesystemofcarethroughthefullpackageofservicestheNPscopeofpracticeaffords.

NPEmploymentBreakdown

Table1:NPEmploymentBreakdown(BCNPA,personalcommunication,July20,2017)

Specialized PrimaryCare

AcuteCare Ambulatory ResidentialPrimaryCarefor

SpecificPopulationsPrimaryCare

Total

FraserHealthAuthority

18 11 3 26 22 80

IslandHealthAuthority 3 11 2 28 15 59

VancouverCoastalHealthAuthority 9 5 4 34 2 54

ProvidenceHealthCare 10 4 0 5 0 19

InteriorHealthAuthority 7 3 2 0 44 56

NorthernHealthAuthority

0 0 0 0 29 29

ProvincialHealthServicesAuthority

13 28 0 19 0 60

Total 60 62 11 112 112 357

133 224

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AcuteCareInacutecareinpatientsettings,NPsasmembersofthehealthcareteam,provideafullrangeofservicesthatincludesthedeliveryofexpertclinicalcareandmedicalmanagementinareassuchascardiology,orthopedics,neurosurgery,trauma,NICUandmulti-organtransplant.SpecialtyNPsinthesesettings,workcollaboratively,managingtheday-to-daymedicalcare,buildingdischargeplansandprovidinghealthself-managementeducationforthepatientsontheunit.NPsprovidestabilityandconsistencyforthepatientaswellastheotherhealthcareprofessionals,andoftenprovidethecohesivepiecesneededforrelationalteambasedapproaches.ThisgroupofNPshasdevelopedspecializedclinicalexpertisebeyondthatofageneralpractitionerorNPworkinginprimarycare.Inadditiontoprovidingdirectcomprehensiveclinicalcareandmanagement,theNPprovidesorganizationalvaluethroughenactingalltheelementsoftheNPscopeofpracticeincludingpromotingeducation/knowledgetranslation,contributingtoevidenceinformedpractice/research,recognizingsystemgaps,andinitiatingqualityassurancestrategiestoimprovethesystemofcare.

InCanada,NPsbeganworkinginacutecaresettings(e.g.,neurology,nephrology)inthelate1980s(Kaasalainenetal.,2010).Severallandmarkstudieshaveconsistentlydemonstratedpositiveoutcomesincludingdecreasedlengthofstay,readmissionratesandco-morbidities(Hiza,Gottschalk,Umpierrez,Bush&Reisman,2015;Collinsetal.,2014;Kapu,Kleinpell&Pilon,2014;Fry,2011;Kilpatricketal.,2010).

InB.C.,thereare60NPspracticinginacutecaresettingsininterdisciplinaryteams.Afewhavebeenevaluateddemonstratingimprovedpatientoutcomesandsignificantcostsavingstothehealthcaresystem:

• Regionally,withintheFraserHealthAuthority,aformalevaluationofthespecializedNProleaddedtothecardiacsurgeryprogramatRoyalColumbianHospitalwascompleted.KeyfindingsdemonstratedsuccessfulNProleintegrationandsustainability,highlevelsofpatientsatisfactionaswellaseffectiveandefficienthigh-qualitycareincludingdecreasedlengthofstay,decreasedtransferstohigheracuityunits,decreasedpost-admissioncomorbidities,decreased30-dayreadmissionratesandincreasednumberofdisease-specificindicatedmedicationsinitiatedorrecommendedatdischarge(Watters,Aaronson,Sobolyeva&Galte,2014).

• AstudyevaluatingtheeffectivenessoftheroleoftheNPinthecardiacsurgeryprogramatSt.Paul’sHospitalinVancouver,alsodemonstratedthateventhoughNPsprovidedcareformorecomplicatedcardiacsurgicalpatients,levelsofpatientsatisfactionandsatisfactionwithpainmanagementwerehigherinpatientsintheNPgroup(Goldie,Prodan-Bhalla,&MacKay,2012).

JenWatters,NP(A),CardiacSurgery-NewWestminster,B.C.Mr.S.isawaitingsurgeryonthecardiacward.Iassumeresponsibilityforhismanagement;ensuringhismultiplechronicconditionsarestableandwillnotinterferewithhisrecoveryfromsurgery.Ireviewwithhimandhisfamilywhattoexpectduringandaftersurgeryandhowtostartpreparingforhisreturnhome.Afterheisstabilizedfromhiscomplexheartsurgery,hereturnstothesurgicalunit.Ireassumedailyresponsibilityforhispostoperativecare,ensuringhisrecoveryissmoothandhischronicconditionsareconsidered,therebyhelpingtoachievehistargetlengthofstay.Preparingfordischarge,Iworkwiththemulti-disciplinaryteamtoensurehehasthesupportsathomeandappropriatefollowupwithhiscommunitynursepractitionerandcardiologist.Safedischargeincludescompletingathoroughdischargesummary,whichprovidesaclearfollowupplanwhichiscommunicatedtohisprimarycareprovider,referringhimtotheoutpatientcardiacrehabilitationprogram,ensuringhismedicationsareoptimizedandstableatdischarge,ensuringcompletenessofhistransitionalinformationfromacutecaretoprimarycareandprovidinghimandhisfamilywithtailorededucationdesignedtopreventfurtherhospitalization.”

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• AtSt.Paul’sHospitalinVancouver,theNProleaddedtotheorthopedicsurgeryteamwasevaluated,anddemonstratedasignificantdecreaseinlengthofstayforhipfracturepatientsbyover30daysaftertheimplementationoftheNProle(Forster,2012).

AmbulatoryCareAmbulatorycareisdefinedasmedicalcareoracutecarethatisprovidedonanoutpatientbasisinspecializedoutpatientsettingsorclinics.Ambulatorycaremayincludediagnosis,management,consultation,advancedmedicalinterventions,proceduresorsurgery,observation,rehabilitation,palliationandtelephoneconsultationservices.TheNPinthisroleprovidessecondarylevelspecialtyservicesonanoutpatientbasisinareassuchasheartfunction,atrialfibrillation,nephrology,asthma,diabetes,oroncologyforbothadultsandchildren.

TheliteraturesupportstheutilizationofNPsinAmbulatoryCareinbothcomplementary(addinganNPtoanexistingteam)andinsomecasesasalternativeproviderstospecialists.Martin-Miseneretal.,(2015)reportthatthereisemergingevidenceindicatingthatNPsinacomplementaryproviderrolewithinaspecializedambulatorycareprogramimprovepatientoutcomes,andNPsinalternativeproviderroleshaveequivalentorbetterpatientoutcomesthancomparatorsandarepotentiallycost-saving.AnotherstudyexaminedtheperformanceofNPsworkinginaspecialtydermatologyambulatorycareprogramandfoundthatthelevelofcareprovidedbyanNPintermsofimprovementsinsymptomseverityandqualityoflifeoutcomeswascomparablewiththatprovidedbyadermatologist.Inaddition,theparentsweremoresatisfiedwiththecarethatwasprovidedbyanNP,whichwereattributedtothe“structure” of the NP interventions and the NP consultation time (Schuttelaar,Vermeulen,Drukker,&Coenraads,2010).

Currently,thereare62NPsworkinginambulatorysettingsinB.C.inadult,olderadult,andpediatricprograms,makingthisthelargestgroupofspecialtyNPsasoutlinedinTable1.AmbulatoryNPsprovidediseasespecificexpertisetoawidearrayofBritishColumbiansaspartofhighlyspecializedmultidisciplinaryteams.TheseNPsareoftenthespecialtyteam’spointofcontactforfollow-upambulatoryvisits,freeingupspecialistresourcesforpatientsthatrequiresub-specialistexpertise.Overall,Martin-Miseneretal.,(2015)reportedthatNPsinspecializedambulatorycaresettingshaveequivalentorbetterpatientoutcomesthan

MinnaMiller,NP(F),PediatricAmbulatoryCareClinic:Asthma–Vancouver,B.C.“Asamemberofthemulti-disciplinaryteam,Iprovideinitialconsultationsandfollowupcaretochildrenwithasthma,andtheirfamilies.Myscopeofpracticeincludesdiagnosisandmanagementofasthma,orderingandinterpretingdiagnostictests,prescribingmedications,referringpatientstosubspecialistsandcollaboratingwithothercliniciansandserviceproviders.Patientandfamilyeducationisanimportantpartofeachclientencounter.Mycaseloadisequaltomyphysiciancounterparts(approximately600patients/year),freeingsub-specialiststofocustheirtimeonmorecomplexcases.Inadditiontoclinicappointments,Iprovidetelephoneconsultationasneeded.IhavecontributedtothedevelopmentanddisseminationoftheBCGuidelinesforChildrenwithAsthma,andinitiatedresearch/qualityimprovementprojectsattheclinicrelatedtointerdisciplinaryteamsandpatientoutcomes.Iserveonthehospital’sasthmaadvisorycommittee,andhavecontributedtothedevelopmentofinternal,agencyspecificpoliciesonpediatricasthmacare.”

Belinda-AnnFurlan,NP(F),AtrialFibrillationClinic-Vancouver,B.C.“IenjoyempoweringpatientsbyimprovingtheirunderstandingofAtrialFibrillationincludingalloftheirspecificrelatedcomorbiditiesandhoweachdiseaseorconditionaffectseachotherlinkingthepatientasawholeperson(hypertension,heartfailure,obstructivesleepapnea,stroke/bleedingrisk,diabetes,obesity).Whenapatientandtheirfamilyunderstandstheirhealthdiagnosis,theroleofpharmacology/non-pharmacologytreatmentandlifestylewithinahealthpromotionandpreventionlenstheyareempoweredandmotivatedtocreatechangeandworkcollaborativelywiththeirfamilyandtheirhealthcareteam.Thisresultsinbetterhealth,wellbeingandqualityoflifeforeachpatientaswellasareductionofhealthcaredollarsspentandburdenonouroverloadedhealthcaresystem.”

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theirphysiciancolleagues.

ResidentialCareTheNPinresidentialcareworkscollaborativelywithinthemultidisciplinaryteamtoprovideregularassessment,diagnosisandtreatmentofmedicalconditionsaspartofholisticadvancedpracticenursingcarewithagoaltodecreasingthefrequencyofurgenthealthcrises.Thisisauniquerole,whichprovidesbothprimaryandspecializedsecondarycarewhiletryingtokeepgeriatricpatientsoutofhospital.Incorporatingapalliativephilosophyofcarewithafrailelderlypopulationcontributestolesshospitaltransfers/admissions,reducedpolypharmacy,andimprovedqualityoflifeandend-of-lifecareforresidentsandtheirfamilies(McAineyetal.,2008).Thisisanenhancedprimarycaremodelforaspecializedpopulationwithafocusonillnessprevention,improvedqualityoflifeandongoingcomprehensivemanagementoffrailresidentswithcomplexhealthconcerns.NursePractitionershaveprovidedservicesinlong-termcare/residential(LTC)carehomesintheUnitedStatessincethe1970sandinCanadasince2000(McCaineyetal.,2008;Stoleeetal.,2006;Futrelletal.,2005).Thistrendhashelpedaddresscriticalissuesinresidentialfacilitiessuchastheincreasingproportionoffrailresidentswithcomplexmedicalissues,limitedphysicianservices,inadequatequalityofcareandescalatinghealthcarecosts(Ploegetal.,2013;Jehan&Nelson,2006;Stoleeetal.,2006).SystematicreviewsoftheliteraturesuggestthattheNPapproachimprovesthehealthstatusandqualityoflifeofolderadultsresidinginresidentialcaresettingsandthattheirfamiliesaremoresatisfiedwiththecareresidentsreceive(Donaldetal.,2013).AsurveyofallphysicianmembersoftheAmericanMedicalDirectorsAssociationsfoundahighlevelofsatisfactionwiththeNProleinLTCamongphysicians(90%),residents(87%)andfamilies(85%)(Rosenfeldetal.,2007).Therearecurrently27,000seniorsinB.C.livinginresidentialcaresettings(SeniorsAdvocateofBritishColumbia,2017),andonly11NPsworkinginresidentialcareintheprovince(BCNPA,2017).TheintegrationofNPsinresidentialcaresettingsinB.C.hasbeenlimiteddespitethisbeinganobvioussettingwhereNPcarecanimprovepatienthealthoutcomes,fillsystemwidegapsincareforavulnerablepopulation,improvetransitionsacrossthesystemofcare,improvetimelyaccesstocareandprovideanconsistent,stable,patient/familycentredapproachforaveryfrailspecializedpopulation.Arecentreport,EveryVoiceCounts,emphasizedtheneedforincreasedaccesstoqualityhealthcareandtheimplementationofNPswithinresidentialsettings(SeniorsAdvocateofBritishColumbia,2017).Todate,thefewNPsinB.C.workinginresidentialcareorwiththehomeboundfrailelderlyhavebeenleadersinsettingupcomprehensiveprogramsinseniors/eldercare,alongwithprogramstoassessanddeliverMedicalAssistanceinDying(MAID)sinceitwasintroducedin2016.NPsareaviablechoicefortheMOH,asB.C.plansforthefutureandworkstoaddressthesignificantandgrowingserviceinadequaciesrelatedtoseniors’care.StrategicdeploymentofNPsinresidentialandlong-termcaresettingsmakessense.Itwillsituatetheirexpertknowledge,skillsandapproachwhereseniorslive,bringingneededrelationshipbasedservicestothishighlycomplex,specializedpopulationcreatingamorepositivecareexperienceforresidentsandfamilies.ImmediatebenefitsandimprovedaccesstocareiswithinreachintheB.C.health

BarbaraRadons,NP(F),ResidentialCare–Surrey,B.C.“Irecentlycaredforafrail90-year-oldwoman,livinginoneoftheresidentialcarecentreIprovidePHCservicesin,andassistedherfamilytopreparefortheirmother’sdeclininghealthandherimminentdeathatthecenter.Thispatientsufferedfromadvanceddementiaandmultiplechronichealthconditions.HerfamilyexpressedgratitudefortherelationshipIhaddevelopedwiththeirmother,thetimethatIwasabletospendwiththem,explainingchangesinhercondition,closelymonitoringherchanginghealthstatus,managinghersymptomspromptlyandfacilitatingapalliativecareapproachattheendofherlife.Theystatedthat“theirmotherhadhadthebestpossiblecareandaverypeacefuldeath.”

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carecontext,andtherearemanyNPsactivelysearchingforemploymentopportunitiestodaywithinthesesettings.

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Clarifying System Challenges StepsTowardaStrategyforNPsWorkinginSpecialtySettingsBuildingontherecommendationsputforthintheBCNPA’sdiscussionpaperPrimaryCareTransformationinBritishColumbia:ANewModeltoIntegrateNursePractitioners(BCNPA,2016),developinganeffectiveandlong-termstrategyforthefulsomeinclusionoftheNProleacrossspecialtysettingsshouldbethenextstepinthereachforlong-termsystemwideimprovements,increasingaccesstohealthandend-of-lifecareforallBritishColumbians.

Aftermorethanadecade,NPshaveemergedaswell-placedprovidersthroughoutthehealthcaresystem,complementingexistingmodelsofcare,andimprovingtransitionalcareacrossthesystem.Withsustainablefundingandcohesive,well-plannedimplementation/integrationprocesses,primarycareandspecializedNProlesnotonlycomplementeachother,butcomplementotherinterdisciplinaryteamandphysicianproviderrolessupportingasynergisticapproachacrosstheintegraltransitionsinpatient’slivesfocusingonimprovingwellness/outcomes,supportingtheappropriateandeffectiveutilizationofspecializedacuteservicesandworkingtoimprovepatientqualityoflife.

Figure2.NursePractitionerServiceModel:AcuteIllnessTrajectory(Galte,C.,2015)

ClarifyingSystemPrioritiesAcrossBritishColumbia,arecentenvironmentalscanrevealed182strategiesoutlinedinHAserviceplanstoaddressidentifiedservicegapsandpopulationneeds,yetonlythreespeaktotheinclusionofNPproviders,includingacute,ambulatoryorresidentialcare.RecentMOHpolicypapersmakementionofNPprovidersin

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ageneralsense,howeverthesepaperscontinuetopresentafocusonphysicianproviders,ratherthaninterdisciplinaryteamsandcomplementaryproviderskillmix,andadistinct,concreteprovincialstrategyorframeworkrelatedtotheutilizationofNPsismissing.Furthermore,NPs,asadvancedpracticenursesareseldomservingonleadershipgroupsengagedintheseprocesses,andasaresultthepotentialoftheimpactofNProleisoftennotcaptured.

Regrettably,whiletherehavebeenmanyverysuccessfulNProlescreatedinB.C.withoutconsultationwithNPs,therehavealsobeenmanyunsuccessfulones,damagingcredibilityfortherole.Thishasresultedinfrustrationandoperationalchallengesforallinvolved,fromthepatient,totheNP,toteammembers,totheHAleadership.TheabsenceoftangiblestrategiesreflectsthelandscapeofcompetingprioritiesinwhichNPintegrationexistsandthelackofNPrepresentationatkeypolicyanddecision-makingtablesseverelylimitsthecontributionthisprovidergroupcouldmakeinaddressingmanyHApriorities.

TheBCNPArecommendsthedevelopmentofastrategyandsystematicapproachtotheintegrationofNPs,whichareoutlinedbelow.GiventhecomplexnatureoftheworkrequiredforthesuccessfulintegrationofNPs,aclearconsistentstrategyisthemosteffectivewaytoensuretheNPworkforcecansupporttheMOHandhealthauthorities’strategicobjectives.Increasinglyacrosslarge-scalechangeinitiatives,thereisevidenceofthebenefitofstructuredprojectmanagementapproaches(Locatelli,Mikic,Kovacevic,Brookes,&Ivanisevic,2017)thatincludeprojectcoordination,implementation,monitoringandevaluation.ThesehavelargelybeenappliedtocapitalprojectssuchastheClinicalSystemsTransformationprojectinthelowermainland,butareincreasinglyseenasanopportunityforothertypesoflarge-scalechange.

LackofaSustainableFunding&RemunerationModelThelackoflong-term,fair,flexibleandsustainableNPfundingmodelremainsthemostsignificantbarriertointegratingandsustainingNProlesacrossthehealthcaresysteminBritishColumbia,includingwithinspecialtycaresettings(Sangster-Gormley,2012;Sangster-Gormley,Martin-Misener,Downe-Wamboldt,&DiCenso,2011;Kilpatricketal.,2010).TheapproachtoNPfundingtodatehasbeenblockfundingdeliveredthroughahealthauthority,withagoaltofundNPsinprimarycare.TheseblockshavecomeprimarilyintwowavesandtheBCNPAhasbeenadvocating,forsometime,fortheMOHtomoveawayfromthisrestrictivefundingapproach,itsburdensomereportingmechanismswithdeliverysolelyviaHA,andmovetowardtheimplementationofsustainablesystemwidefundingsolutionsforNProles,nomatterwheretheyareintroduced.

ThecurrentapproachhasledtoseveralchallengesbothforHA’sandcommunities.Firstly,whenfundingcomesinwaves,itrisksinappropriateandunsuccessfulroleimplementation,asthereisoftennotenoughtimeforcomprehensiveroledevelopmentamidtheurgencytosecurethefundingopportunitybeforetheapplicationdeadlineandinsomecases,implementationoccurswhenanotherproviderrole(RegisteredNurse,ClinicalNurseSpecialistorPhysician)mayhavebeenmoreappropriate.Secondly,gapsinfundingwaves(thelastwaveoffundingendedinearly2015)makeitchallengingforHAstobuildonsuccessfulNProles,toimplementcomplementaryNPproviderswithinexitingteamsortocreatenewmodelsofinterdisciplinarycaretoaddressservicegaps.Thirdly,thisfundingstructurehaslimitedflexibility,inthatitplacestheNPstobesolelyemployedwithinHealthAuthoritieswithnooptionsforpart-timeorcontractedwork.Aswell,theemployeerelationshipinmostinstances(reportingthroughProgramManagers)leavestheNPwithlimitedinfluenceinprogramplanningtoaddressidentifiedservicegapsandlimitedflexibilitytomeetthechangingneedsofthepatientpopulationsinthemostsuitablelocations.Furthermore,communitiesneedingservicemustgothroughaHAtosecureNPfundingwhichisoftenlogisticallychallenging.

AsustainableNPfundingmodelcannotberealizedwithoutacommitmentfromtheMOH,andBCNPAisrecommendingan“investtosave”approachandthedevelopmentofasimple,consistent,sustainable

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provincialNPfundingstrategythatwouldallowHA’sand/orcommunities,whetherprimary,acute,ambulatoryorresidentialcaretobenimbleandresponsivetochangingpopulationandserviceneedswhentheyariseenablingtheutilizationoftheNP’scompletebasketofservicestocontributetoimprovedaccesstocareandsystemwideresponsiveness.

1. Recommendation:DevelopaSustainableSalary-basedFundingFrameworkGovernmentandhealthsystemplannersmustconsiderhowtobestmaximizetheNPworkforcebeyondprimarycareandincludestrategiesthatacknowledgethepotentialofNPcareinspecialtypracticeareaswithinspecialtyteams.AsoutlinedinPrimaryCareTransformationinBritishColumbia:ANewModeltoIntegrateNursePractitioners(BCNPA,2016),asustainablesourceoffundingforNPsiscriticaltoensureBritishColumbiansandinterdisciplinaryteamscanrealizethefullbenefitsoftheNProle.

Asimple,consistentsalaryorblendedandvaluesbasedfundingframeworkforNPswouldsupporttheinclusionofNPsacrossthecontinuumofcare,nomatterwhereemploymentoccurs,andthiswouldincludeNPsworkinginacutespecialtycare,ambulatoryandresidentialcare,andwouldalsoprovideoptionsforinnovativecost-effectivecaremodelsinthenon-profithealthsector.Multidisciplinaryteam-basedsalariedmodelsareattractivetonewgraduatesacrossdisciplines,astheyofferastableandpredictableincome,anopportunitytoworkcollaborativelywithotherhealthcareprofessionalsandpositivework/lifebalance.Fundingsourcescouldinclude:

• Fundingwithinanexistinghealthauthority-operatingbudget.

• FundingexternaltothehealthauthorityutilizingtheAPP.

• FundingexternaltothehealthauthorityutilizinganAPP-likeNPmodel.

BCNPArecognizesthatfundingisnotunlimited.RealigningscarcehealthcarefundingdollarprioritieswithinexistingMOHbudgets,whilechallenging,mustbeundertakentobetterreflectthehealthcareneedsofpatientstoday.DiscussionofbudgetsandcostconsiderationscanbefoundindetailinPrimaryHealthCareTransformation:ANewModelforNursePractitioners(BCNPA,2016);thesehavebeenupdatedandincludedinAppendixAandB.NPfundingoptionsinclude:

• OptionA:HA-Employed

• OptionB:HA-Affiliated

ItisBCNPA’spositionthattheseapproacheswouldprovidestable,sustainablefundingforNPsinspecialtycaresettings,wouldnotbechallengingtoadministerandwouldpositiontheNPworkforceasaviablecomplementaryorinsomesituationsalternativeprovidertophysicianswiththepotentialtoyieldsystemwideefficienciesandcostsavingsinadditiontoimprovinghealthcareoutcomes,todayandinthefuture.

LackofaQualityAssuranceFramework Highqualityhealthcareistheoverarchinggoalofallhealthcarepolicy,planningandsystemdelivery.Evaluationandperformancemeasurementhavebecomefamiliarvocabularyinmosthealthcaresettings.TheCanadianInstituteforHealthinformation(CIHI)suggeststhatperformancemeasurementframeworksmustmeettheinformationneedsofthegeneralpublic,policy-makersandhealthsystemmanagers(CIHI,2013).Thepressingquestiontodayishowdohealthcareleadersandplannersensurevalueoutcomesgiventhesubstantialpublicresourcesspentdeliveringhealthcaretoday(Kleinpell,2005).

EvaluationandcontinuousqualityimprovementactivitiesareinplaceacrossHAstoday,andaredesignedtoprovidedatathatsupportstheefficient,effectiveuseofavailablehealthcaredollarsandtodemonstratethattheoverallgoalsoftheMOH,theHA,thecommunityandofcoursethepatientswhoarerecipientsoftheservicesdeliveredareachieved. However, evaluationframeworkstoooftencapturethelowhanging

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fruit,inthatitiseasytounderstandthenumberofpatientvisits,patientsseen,procedurescompleted,infectionrates,births,deaths,bedsavailable,surgicalwaitlists–butdothesenumbersprovideenoughinformationtoensuregoodvalueandhigh-qualitycare?

BCNPAunderstandstheneedtobringcontinuouscriticalreflectiontoallpracticesettings,evaluatingnotonlynumericalstatisticsandservicesutilization,buttolookmorebroadlyatpatientspecificoutcomes/experiences,healthequity,socialdeterminantsofhealthindicators,humanresourcesallocation,systemgaps,systemwaste,andpotentialsolutionsorchangestoaddressthosegapswithafiscalandpatientlens.SeveralevaluationframeworksexisttodaythatwillbeusefulinunderstandingtheimpactofNPpracticeonpatienthealthoutcomes,organizationalpriorities,multidisciplinaryteamfunctioning,andsystemresponsiveness.Bryant-Lukosiusetal.(2016)developedanevaluationframeworkthatholdspromiseasafulsomeevaluationframeworkwithNPsensitiveoutcomesinparticularasshowninFigure3.

Figure3.FrameworkforEvaluatingtheImpactofAdvancedPracticeNursingRoles(Bryant-Lukosiusetal.,2016)

ThisFrameworkforEvaluatingtheImpactofAPNRoles(2016)coupledwiththeCanadianInstituteofHealthInformation’sNewHealthSystemPerformanceMeasurementFramework(2013)wouldallowforthemeasurementofNPspecificoutcomeswithinthecontextofbroaderhealthsystemoutcomemeasuresasoutlinedinFigure4.ThesearejusttwoqualityassuranceframeworksthatcanprovideausefulstartingpointastheprovincelookstoensurethatNPsareaddingvaluetothebroadersystemofcareincludingspecialtyandsubspecialtyprograms(CIHI,2013).

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Figure4.CIHI’sNewHealthSystemPerformanceMeasurementFramework(CIHI,2013)

ExpandingtheNPworkforceinspecialtysettingsorintheprovisionofcareforspecializedpopulations(vulnerable/marginalized)isanexcellentopportunityfortheMOHtoobtainbroaderinnovativehealthoutcomedata,tobettersupportimproveddecisionmakingandworkforcedeploymentbasedonpatientneedandpopulatonhealthoutcomes.

2. Recommendation:Develop,AdoptandImplementQualityAssuranceFrameworkDevelopprogram/teamlogicmodelstomeasureNPspecificoutcomesasaneffectivemeanstosupportconsistencyinevaluationandqualityassuranceactivitiesspecificallyrelatedtoNPcareandthevalueofaddinganNPtoaspecializedcareteam(SeeToolkit).

Developandimplementastandardframeworkdemonstratingalignmentwithagreedupongoalsofcareandpositivepatientoutcomesforeverynewmodelofserviceimplemented.ThequalityassuranceframeworkcouldincludebroadhealthsystemsoutcomesthatareestablishedprovinciallywithininterdisciplinaryteamsalongwithadditionalNPspecificandteam-basedoutcomes.

Out-DatedNPRemunerationNPremunerationisessentiallyunchangedsincetheinitialMOHblockofNPfundingin2005.Thefirstremunerationpackagewassalaryplusnon-salarycompensationthatincludedadministrativesupport,officeequipmentandcontinuingeducationfundsforatotalof$146,000/NPposition.Thesecondblock,NP4BC(2012-2015),providedNPsalarycompensationperpositionatthesamerate(basedon2005levels),butdidnotincludethenon-salarycompensationrequiredforsuccessfulimplementationofanNPposition,leavingHAswithlimitedmechanismstoofferessentialnon-salarysupport,andinmanyinstanceseffectivelydecreasingtheoriginalnon-salarysupportasthesedollarsweredistributedbetweentheoriginallyfunded

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NPsandtheNP4BCfundedNPs.Thissecondroundoftargetedfunding,earmarkedtoincreaseaccesstoprimarycare,hadtheunexpectedoutcomeofimprovingaccesstospecializedhealthcareformanyveryunderservedpopulations,asNPemploymentopportunitieswerecreatedtoprovidearangeofspecializedhealthcareservicesformedicallycomplex,highneedspopulationsbothinprimarycareandacutecarespecializedsettings.

Since2005,NPscopeofpracticeandNProleshaveexpandedandbroadenedtoincludeprescribingofcontrolleddrugsandsubstances,admittinganddischargingpatients,opioidagonisttherapyandtheprovisionofMAiD,enablingNPstofullyparticipateasactivemembersofhighlyspecializedhealthcareteams.Sincethattime,muchhasbeenlearnedaboutthecontributionsthatNPsinspecialtycarehavemadeandcontinuetomakeacrossthesystem.Despitethis,NPremuneration,regardlessofemploymentsettingremainsessentiallyunchangedandhasnotkeptupwith2017compensationpackagesforsimilarprofessionalgroups(e.g.PhysicianandMidwiferyMasterAgreements)nordoesitreflectthecomplexclinicalworkthatNPsareprovidingtodayinspecialtysettings.

WhilethebaserateofremunerationisimportanttoconsiderwhendeterminingamorereflectivesalaryforNPs,itisnottheonlyone.AsthescopeofpracticeofNPshasincreased,sotoohasrecognitionofthecontributionstheNProlehasmadetohealthcareteams.OverthelastseveralyearstherehasbeendiscussionabouttheneedforfundingmechanismsthatallowNPstoparticipateincallgroups,workweekendsandevenings,andhavelocumcoverageavailablewhentheyareawayonvacation.DeterminingappropriatefundingmechanismsandestablishingthebestapproachesthatconsiderallaspectsofNPworkalongsideemployerneedswilltakeaconsiderableamountofdiscussionandstakeholderinvolvement.Approachesandfundingmechanismsmaylookdifferentlycase-by-casedependingontheNPand/oremployer.

AlsoproblematicisthecurrentHealthEmployersAssociationofB.C.(HEABC)noncontractsalarygrid,asitexists.Thisgriddoesnotalignwiththepracticeofacliniciangroup(NPorMD).Designedprimarilyforhealthcaremanagementpersonnel,salariesaretiedtoperformancemeasuresthatreflectmanagerial/administrativeperformanceratherthanclinicalworkperformance.Assuch,performancemeasuresdonotalignwithtypicalNPpracticeandthecontributionsoftheNParelargelyinvisibleorarechallengingfortheNPtoarticulate.ThismismatchleadstomisunderstandingamonghealthcaremanagersanddirectorswhentryingtoevaluateNPperformance,contributestoroleconfusion,andaddstopoorjobsatisfaction.NPsalsoreachthetopofthegridwithinadecade,leavinglittleroomforadvancementandnorecognitionofadditionalexpertisetheNPmayacquire.NPsareuniqueinthattheyprovideaclinicalleadershiprolealongwithaclinicalpracticeroleandthereisnomechanismwithinthecurrentHEABCsalarygridtorecognizeandsupportthisimportantaspectNPscontributetothebroadersystem.

Simplyput,theissueofremunerationforNPswithspecializedpracticesisthreefold:

• Basesalaryhasnotkeptupwiththeincreasedresponsibilityormarketcompetitionandnon-salaryrelatedsupportfundingisinsufficientormissingformanyNPpositions.

• Thecurrentremunerationdoesnotincludecallorlocumcoverageoramechanismtoprovideforthisiftheseservicesarerequiredtomeetpatientneeds.

• BasesalarygridasperHEABCisnotapplicabletoclinicianprovidersanddoesnotreflectleadershipactivitiesoradditionalformallyacquiredexpertise.

3. Recommendation:DevelopaWorkingGrouptoReviewandUpdateNPRemunerationDuetothecomplexityofthisissue,BCNPAsuggeststhedevelopmentofaWorkingGrouptoestablishappropriatevaluesbasedremunerationthatismorereflectiveofthecurrentstateandscopeofNPpractice.TheworkinggroupshouldincluderepresentativesofAdult,PediatricandFamilyNPsworking

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acrossvariedsettings,NPpracticeleadersinthehealthauthorities,NNPBC,CNOs,MOH,theChiefNursingSecretariat,HEABCrepresentativesandexpertsinclinicalcompensationpackages.TheBCNPArecommendsthattheworkinggroup:

1. RevisebaseremunerationpackagesforNPsincludingsalary,benefits,ongoingeducationfunds,andoverheadcosts,andestablishaprocessforregularreviewofremunerationtoensuremarketcompetitiveness.

2. Identifyarealistic,fairremunerationmechanismforNPsprovidingservicesoncall.Unlikeotherclinicianswhohavedependentcontractswiththehealthauthorities,NPsareemployeeswhodonotbillMSP,whichmakesfaircompensationdifficulttosortout.Therearealsodifferenttypesofcall(coveringlabsvs.takingcallsandattendingtopatients)andnumerouswaystoprovidecompensationforcallincludinganincreaseinbasesalary,timeinlieuorovertime,whichareoutlinedinthePhysicianMasterAgreement(B.C.MOH,2014a)andintheMOCAPRedesignPanelReport(B.C.MOH,2013).GiventhattheNPisprovidingsimilarservicesasotherclinicianssuchashospitalistsandmidwives,amasteragreementforsomeNProlesmayalsobeanoptionforconsideration.

3. DevelopanHEABCNon-ContractClinicianSpecificsalarygridincollaborationwithNPsthatbetterreflectstheclinicalworkthattheNPprovidesandwouldallowforimprovedperformancebasedcompensation.ThisrecommendationisnotonlyaboutupdatingthebasesalarybutstrivestoensurethatHAoperationshavethenecessaryfundingtofullymaximizetheutilizationoftheNPgrouptomeetorganizationalpriorities.HealthAuthoritiesmayalsofindthenewsalarygridapplicabletootheremployednon-contractclinicians.

LackofaHealthHumanResourcesStrategyHealthhumanresources(HHR)areoneofthemostimportantcontributorstothefunctioningofthehealthcaresystem.Timelyaccesstohealthcareisdependentontherightmixandvolumeofhealthcareprofessionalsintherightsetting.Thisinturnensurestherightproviderattherighttimefortherightcost,afiscallyresponsibleapproachgiventhelimitationsonhealthcarebudgets.HHRplanninginvolvesplanning,productionandmanagementprocesses.Planningisthemostintegralsteptoidentifyingcurrentandfutureneed,theavailablesupplytomeettheneed,andthedemandonhealthprofessionalswhoaredeliveringcare(Dreeschetal.,2005).Oncethegapbetweenrequirementsandavailablesupplyaredetermined,policiestosupportinitiativestobridgethedividecanbeimplemented(Birchetal.,2007).Unfortunately,thisstepwasmissedwhenNPswerefirstimplementedinB.C.leavingaworkforcethatisnotbeingutilizedtotheirfullpotentialandunlessahumanresourcesstrategyisimplementedimminently,isatriskforfurtherinefficiencies.

IntegratingstrategicdeploymentofNPswithininterdisciplinaryforecastingmodelswouldprovideacompletepictureofwhereNPswouldbebestsituatedaspartofcollaborativeteams,ensuringsuccessfulimplementationinkeypriorityareas.Planningshouldconsiderfactorssuchascurrentwaitlists,predictivemodelsofpopulationhealthneeds,patientcomplexityandprovidercompetenciestoensurepatienthealthneedsandsystemgapsareaddressed.CIHI’span-CanadianNPdatacancontributesubstantiallytoforecastingNPHHRneedinB.C.BCNPArecognizesthatimprovedplanningaroundtherequiredNPworkforceandpriorityareasoverthenextdecadeisanintegralsteptothesustainabilityoftheNProleinB.Cwhichwilleffectivelycontributetoamorefulsome,responsivehealthcaresystem.

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In2006,theCNPIdevelopedaHealthHumanResourcesStrategytoassistprovincesindeterminingcurrentandfuturerequirementsforNPs,componentsofwhichwouldbeusefulindeterminingaprovincialstrategy(CNPI,2006).InadditiontotheCNPIHHRStrategy,twoothermodelsthatholdpromiseforplanningoftheNPworkforceareoutlinedbyBirchetal.,(2007)andDreeschetal.,(2005).TheDreeschModel(Figure5)wasdevelopedasaresponsetotheWorldHealthOrganizationMillenniumDevelopmentGoalsandseekstoalignhumanresourceplanningwithspecificinterventionsandthehealthprofessionalskillsetsrequiredtoachieveaspecifichealthoutcome.ThismodelholdspromiseinthatNPhumanresourceplanningcouldbealignedwiththerequiredskillsandservicesthatareidentifiedtoachieveprovincialgoalsforhealthcarereform.AnexampleofthiswouldbethedevelopmentofanNPstrategichealthhumanresourceplandirectedatmanagementofmentalhealthandsubstanceuse,dementiacareorcareofthefrailelderly.Thegraphicbelowdescribesthelogicandinteractionofthismodel:

Figure5.AnApproachtoEstimatingHumanResourcesRequirementtoAchievetheMillenniumDevelopmentGoals(Dreeschetal.,2005)

4. Recommendation:DevelopaHHRStrategytoNPDeploymentGiventhepredictedchangesinboththedemographicsofhealthcareprovidersandthepopulationinB.C.andCanada,astrategichealthhumanresourceapproachforNPdeploymentshouldbeundertakeninB.C.TheMOHshoulddevelopaclearvisionofdesiredoutcomes,determinethecurrentsupplyofNPsandworktoanticipatethefuturedemandtoensureappropriateresourceallocation/utilizationtomeetMOHgoals.

5. Recommendation:EmployNPsandIncreaseEducationalSeatsAccordingtotheHHRStrategyBasedonarobustHHRplan(above)andthepopulationhealthneedsorsystem/servicegapdefined,systemleaderscanidentifytheinterdisciplinarymixofcliniciansincludingNPsrequiredtobestmeetpatientneed.AppropriatenumbersofAcute,AmbulatoryandResidentialNPscanbeeducatedandemployedinareasofidentifiedneedaccordingly.AcorrespondingincreaseinthenumberofNPgraduatesfromB.C.programswilllikelyberequired,giventherestrictednumberofNPeducationalseatsandNPeducationalprogramsintheprovincetoday.

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HHRPlanningExampleBasedonDreeschModel(Dreeschetal.,2005)

CaseExample-DowntownEastsideinVancouverIdentifyNeedforService-ComprehensiveMentalHealthandSubstanceUseApproach-goaltodecreasefentanyloverdoses

2017-914January-September2017whichis147%increasefrom2016-ifratescontinue-aprojected2,285willrequireservice(MinistryofPublicSafetyandSolicitorGeneral,2017)

IdentifyInterventionsRequired

• PatientMedicalHomeswithwraparoundservicesthatareavailableandbarrierfree

• Housingandemploymentavailability

• SubstanceSpecialtyCarelinkingbothprimaryandacutecaresettingswithfocusonharmreduction,preventionandbuildingtrustingrelationships

•MentalHealthSpecialtyCarelinkingbothprimaryandacutecaresettingswithfocusonharmreduction,preventionandbuildingtrustingrelationships

• Transitionalmodelofcare.

IdentifyTasksandSkillsRequired

• PrimaryCareProviderworkinginanon-FFSmodelwithanequitybasedapproachthatwillincludeworkingwithpatientsandtheircommunityonhousingandemployment

• SubstanceUseSpecialists–trainedinOAT

•MentalHealthSpecialists

IdentifyTimeRequirementsNPstakingcareofverycomplexpopulationswillhavearosterof400-600patients(Martin-Miseneretal.,2015).Ifworkinginawrap-aroundteamwithsocialworkers,GPs,addictionscounsellorsandpharmacists,thenumbercouldbe600-800-onaverage-600.TheNPcouldfollowpatientsfromprimaryhealthcareintoacutecareandbackintocommunitywithinaspecializedrole.

IdentifyOverlap/SynergiesNPsandGPshavesimilarskillsetandwilloverlapinbothsubstanceuseandmentalhealthexpertise-anyHHRplanningwillincludeGPsandroleswillbecomplementary.

EstimateNPFTE4FTEfor2285patients(NPsintegratedintointerdisciplinaryteamswithrosterof600)

EstimatedCost$774,976(AppendixC)

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NPEducationalProgramsNotReflectiveofEmploymentOpportunitiesInB.C.,therearethreeregulatedNPstreamsofpractice–Family,AdultandPediatric(Figure6).Intheadultandpediatricstreams,NPsworkwiththeserespectivepopulationsallowingforamorefocusedareaofexpertise.TheAdultandPediatricNPs’in-deptheducation,skillsandcompetenciespreparethemtoworkwithspecialtypopulationsinacutecareand/orspecialtypracticesettings.However,in2005,tosupporttheMOHfocusonincreasingaccesstoprimarycare,theMinistryofAdvancedEducationandMOHcommittedtofundingFamilyNPprogramsonly,offeredatthreeB.C.universities:UBC,UVICandUNBC.CandidateswishingtoaccessMastersNPeducationinAdultorPediatricsmustseekoutprogramsinotherprovincessuchastheUniversityofAlberta,UniversityofTorontoorintheU.S.suchasTheUniversityofWashington.

Figure6.NPsinB.C.byStream/Category(CRNBC,personalcommunication,March9,2017)

SincetheinitialimplementationoftheNProleinB.C.,therehavebeeninconsistenciesbetweenthenumberofgraduatingFamilyNPsandthecommunity/primarycareemploymentopportunitiesavailable,despitethenumberofBritishColumbianswithoutconsistentaccesstoprimarycare.Thislackofopportunitytopracticeinprimary/communitybasedcare,coupledwiththegapsinacuteandsub-specialtycareprogramshasledmanyFamilyNPstoseekrolesofferedinacutecaresettings.Interestingly,thisphenomenonisoccurringnationally,whereitisreportedthatthenumberofNPsworkingincommunitysettingshasdecreasedsince2005from58percentto32percentandthoseworkinginhospital/acutesettingshasincreasedfrom28percentto40percentdespitethefocusonprimarycareasoutlinedinFigure7(CNPI,2016).TheBCNPArecognizesthatthishasoccurredduetomultiplefactors,however,mostnotablyinB.C.,NPfundingwassolelyprovidedtoHAswhichareexpertandmandatedintheprovisionofacuteandspecialtycareservices,ratherthanprimarycareservices.Furthermore,thedeliveryofprimarycareinB.C.todayresideswithfamilyphysicianprivatepractice,stronglysupportedthroughtheGeneralPracticeServicesCommittee(GPSC)withagoaltofacilitateprimarycaretransformation.NPsintheprovinceareexcludedfromthisprimarycareinitiative.Inaddition,itisdisturbingthattherehasalsobeenareductionofNPsworkinginruralareasoverthelastdecade-from29percentto18percentfurthercompromisinghealthcaredeliveryinruralareas(CNPI,2016).

90%

7%

3%

NPsinB.C.byStream/Category

Family

Adult

Pediatric

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Figure7.PlaceofWorkAmongNPsinCanada,2005and2014(CNPI,2016)

OftheNPsworkinginspecialtyrolesinB.C.today,someareAdultorPediatricNPseducatedinotherjurisdictions,however,themajorityareFamilyNPgraduatesofB.C.universityprograms.ManyoftheseFamilyNPsbringvaluableclinicalskillsandregisterednursingexperiencetothosepracticesettings,howeversomearenewgraduateNPs,withoutpreviousexpertise,whomustacquireadditionaleducation,mentorshipandclinicalexperiencetodevelopthecompetenciesrequiredtoprovidefulsomeclinicalcareinaspecializedNProle.Forexample,aFamilyNPgraduatewhohasseveralyearsoforthopedicexperienceasaRN,willlikelypossesstheadditionalexpertknowledgeandcompetenciesrequiredforaspecializedcareroleaspartofanorthopedicteam,whereasaFamilyNPgraduatelackingthisspecificRNexperiencewillneedadditionaltrainingtoacquirespecializedcompetencies.B.C.ismissinganopportunitytoimproveaccesstoacutecareservicesandtoimproveacutecareservicedeliverybylimitingtheprovincetooneeducationalprogram-MNNP(Family).

Anearlyattemptin2002/2003bytheBritishColumbiaInstituteofTechnology(BCIT)toaddresstheeducationalgapintermsoftheAdultNPstreamofpracticewasnotsustainable.BCIT’sSpecialtyNursingProgramsexploredtheneedforanAdultacutecarefocusedNPprograminresponsetotwokeyevents:TheMinistryofAdvancedEducationgrantedBCITtheprivilegeofofferingAppliedMastersdegreesin2002,andthegovernmentproposedlegislationallowingNPpracticeinB.C.ThefacultyconductedanenvironmentalsurveytodeterminetheneedforanAdultNPpost-master’sprograminB.C.overatwo-yearspan,revealingsolidsupportfrommultiplestakeholders(healthcareagencies,studentgroupsandprofessionalbodies)forthedevelopmentofanAdultNPprogrampreparingNPstopracticeinspecializedsettings.TheprogramwasdevelopedandthefirstcohortofstudentswasadmittedinAugust2005.Unfortunately,theprogramfacedmanychallenges,mostnotablyalackoffundingduetoafocusonFamilyNPeducationprogramsinotherinstitutions,thatthreateneditssustainability.This,alongwithlackofpublicawarenessabouttheBCITprogramandAdultNPstreamofpracticeledtolowenrollmentandsubsequentdismantlingoftheprogram.

6. Recommendation:ReviewandUpdateEducationinB.C.toReflectPopulationNeedsReopendiscussionsregardingestablishingAdultandPediatricNPprogramsintheprovinceas40%ofNPsarepracticingwiththesespecialtypopulations.ItisimportanttonotethattheBCITcurriculumisstillavailableforusebyMOHandMinistryofAdvancedEducationandSkillsTrainingandthereiswillingnessforengagementandparticipationbyoriginalfaculty.

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LackofPostgraduateNPEducationDuetothesmallnumberofAdultandPediatricNPslicensedinB.C.,alargenumberofgraduatingFamilyNPsarebeingactivelyrecruitedandhiredintopositionssupportingdisease-specificspecializedpopulationsinspecialtysettings,oftenwithouttheadditionalexpertisetoprovidethecomprehensivecaretheroledemandsasdescribedabove.ManyNPsworkinginspecialtyroleshavepriornursingexperienceintheseareas,however,thisisnotalwaysthecase.ThisisaconcernraisedregularlybytheNPshiredintopositionsaswellastheHAemployersastheNPseeksexpertiseinadditionalclinicalskills.ThisissueimpactsteamandorganizationalefficiencyandultimatelyhasthepotentialtoimpacttheefficientdeliveryofservicestothepatientaswellasdamagesthecredibilityoftheNProle.

Additionally,thereisalackofstandardizationamongHAswithrespecttotraining/support/mentoringprogramsforNPsworkingonspecialty,acute,andmulti-disciplinaryteams(e.g.,palliative,trauma,HIV,ICU,etc.)andtheCRNBCdoesnotprovideorrecognizespecialtypracticecertificationsforNPs.ThisissueisfurthercomplicatedwhenthefullylicensednoviceNPwhoisprovidedadvancedclinicaltrainingisconfusedwithmedicalresidentsorstudenttraineesratherthanrecognizedasaqualifiedproviderseekingadditionalexpertise.Thesituationoftencontributestoalackofsupportfromotherhealthprofessions(e.g.,hospitalists,orotherspecialists)whomightquestionanNPscompetencetopracticeinaspecialtycarerole.

ManyU.S.authorspointoutthatafellowshipmodelhasbeensuccessfulforphysiciancolleaguesnewtoaspecializedrole(Andrade,2015;Kells,Dunn,Melchiono&Burke,2015;Wojneretal.,2009).Kells,Dunn,MelchionoandBurke(2015)pointoutthatwhilevariableon-the-jobtrainingmaybehelpfultoskilledNPsenteringspecialisedareasofpractice,thisapproachlacksthein-depthstructurethataformalfellowshipprogramwithcertificationcanprovide.

Currentprovincialexamplesofstandalonehospital-basedspecificNPFellowshipmodelsforsub-specialtypracticeexist;mostnotablyforNPsworkingintheICUsettingatAbbotsfordRegionalHospitalandNPsworkinginCardiacSurgeryatRoyalColumbianHospital.BCWomen’sHospitalhasalsorecentlydevelopedaNeonatalNPfellowship,whichwillprepareFamilyandPediatricNPsforclinicalrolesintheNICU.However,thesefellowshipsarelocallybasedanddonotprovideNPswiththerecognizedcredentialstomovefromoneHAtoanother.Ideally,fellowshipmodelsshouldbedevelopedjointlybetweenacademicinstitutionsandaffiliatedhealthauthorityagenciesensuringstandardizedrecognizedcredentialingaswellasportability.

7.Recommendation:DevelopNPPostgraduateFellowshipProgramsProvidingaconsistentstructuredapproachintheformofpostgraduatefellowshipswillallowFamilyNPgraduatestosuccessfullyacquirethecompetenciestoworkinaspecialtysetting,effectivelycontributingtoimprovedhealthoutcomesforthepatientsserved.BCITspecialtyprogramscouldbedevelopedtoensurethedevelopmentandmaintenanceofcompetenciesforFamilyNPs.

Initially,practicalclinicaltrainingcompetencyacquisitionmayneedtoinvolvespecialistphysiciansasmentors/clinicalresources,however,theultimategoaloftheNPFellowshipprocessmustbetohavequalifiedNPsprovidethisadvancedlearning.HAsmusttakealeadershiproleinsupportingthistypeofpostgraduatelearning,withfundingsupportfromtheMOH.

BCNPArecommendsthatpostgraduateNPFellowshipprogramsbeprovincial,credentialedandprovidedinaffiliationwithanaccrediteduniversity.Thistypeofmodelalreadyexistsincertainareas–suchastheFellowshipforNPsattheBCCentreforSubstanceUse,whichisrecognizedprovincially.

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LackofaStandardizedProfessionalPracticeFrameworkTheabsenceofaProfessionalPracticeFrameworkinB.C.,thatincludesastandardizedapproachtoNProledevelopmentandintegrationhasledtoinconsistentimplementationofNProlesacrosstheprovince,roleconfusion,uncertaintyaboutpriorityareasforNProles,failedroles,andsub-optimaloutcomemeasurementmetrics.Schober,GerrishandMcDonnell(2015)examinedpolicydevelopmentforNPsandhowpolicytranslatesintopractice.Theyconcludedthatstrategicplanningutilizingaframeworkwasessentialforfullandseamlessintegration.

TheAmericanNursesCredentialingCenterMagnetApplicationManualdefinesaprofessionalpracticemodelas“theoverarchingconceptualframeworkfornurses,nursingcare,andinter-professionalpatientcare.Itisaschematicdescriptionofasystem,theory,orphenomenonthatdepictshownursespractice,collaborate,communicate,anddevelopprofessionallytoprovidethehighest-qualitycareforthoseservedbytheorganization”(Silverstein&Kowalski,2017,“ProfessionalPracticeModelDefined”).TheinabilitytosuccessfullyintegrateNPsintohealthcareteamsfrequentlyoccurswhenthereisambiguityandnoclearvisionofhowtheroleshouldbeintegratedintoexistingsystems(Elliott&Walden,2014).Becauseofthis,magnethospitalsintheU.S.arerequiredtohaveaprofessionalpracticeframework(Silverstein&Kowalski,2017).

AcursoryliteraturereviewrevealsnumerousProfessionalPracticeFrameworksthatcanbeadaptedtofittheB.C.context(Elliott&Walden,2014;DiCensoetal.,2007;CNPI,2006;Byrant-Lekosius&DiCenso,2004).UtilizingexistingframeworkstoestablishaguidetoamodelofcarefortheNProleinB.C.willimproveconsistency,roleclarityandtheabilitytomeasuresimilaroutcomesacrosstheprovince.Inaddition,itwillfacilitateorganizationalunderstandingaboutthevalueoftheNProle,andwillcontributetoappropriateutilizationoftheNProleinfutureplanning.TheTransformationalAdvancedProfessionalPracticeModel(TAPP)isjustoneexampleofatransformationalNPpracticemodel,whichincludessixprofessionaldevelopmentdomainsandonepatientcaredomainasshowninFigure8(Elliott&Walden,2014).ThisframeworkcouldbecoupledwithprojectmanagementapproachestorealizethebenefitoftheNP.Executionofsuchaframeworkmustreflecttheuniquenatureofregionalandlocalcommunities’characteristics,needsandgoals,andshouldconsidertheintegrationofNPsacrossthecontinuumofcare.TheBCNPAhasdevelopedaToolkitasacompanionpiecetothisdocumentthatwillbeausefulplatformforaprovincialframeworkandarobustroledevelopmentandimplementationstrategy(SeeToolkit).

8.Recommendation:AdoptaProfessionalPracticeFrameworktoEnableaStandardizedApproachDeveloporadoptaprovincialNPprofessionalpracticeframeworkensuringsuccessfulconsistentNProleimplementationorintegrationacrosstheprovince.TheadoptionofaprovincialframeworkwouldprovideHAswithasolidplatformforNProleintegration,andensureroleclaritythatwouldincorporatethelocalcontextandpatientpopulationneeds.AclearframeworkwillalsoimproverecruitmentandretentionofNPsovertime(Robinson,Eck,Keck,&Wells,2013).

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Figure8.TheTransformationalAdvancedProfessionalPracticeModel(Elliot&Walden,2014)

PersistingIssueswithRoleClarityRoleconfusionhasbeenidentifiednumeroustimesasoneofthekeybarrierstothesuccessfulintegrationoftheNPprovider(Sangster-Gormley,2012;Bryant-Lukosiusetal.,2010;DiCensoetal.,2010;Donaldetal.,2010;DiCensoetal.,2007).Despiteavailableeducation,pamphlets,flyers,slidepresentationsandformaladvertisingcampaigns,(e.g.,“It’sAboutTime”Campaign,CNA,2013),therecontinuestobemisunderstandingandmisinformationabouttheNPscopeofpracticebothinternallywithinnursingandexternallyamongotherhealthcaredisciplinesandthepublic.ThiscontributestoincreasingambiguityandcontinuestobeamajorbarriertoeffectiveintegrationofNPsinB.C.

Withinthenursingcommunity,thereisapersistentlackofclarityaboutthetwodistinctAdvancedPracticeNursingroles,theNProleandtheClinicalNurseSpecialist(CNS)role.ThesearecomplementarymasterspreparedroleswithinnursingandwhileNPscopeofpractice,thebroadestinthenursingprofession,doesoverlapwiththepracticeoftheCNS,theNProlefocusesprimarilyonthedeliveryofclinicalcarewhiletheCNSprovidesastrongeremphasisonsystemchangesandbestpractice.TheNPandCNSrolesarecomplementaryandworkwelltogetheraddressinggapsinpatientcarefromthebedsidetothebroadersystemasawhole(McNamara,Lepage,&Boileau,2011;Carteretal.,2010).Unfortunately,thesecomplementaryrolesareoftenhamperedbyalackoffunding,andareoftenconsideredeither/orbyplanners,andconsequentlyarenotoftenfoundtogetherinB.C.resultinginadetrimenttothesystem.

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Withinthebroaderhealthcarecommunity,NPsandPhysicianAssistants(PA)areoftendescribedashavinginterchangeableroleswithsimilarscopesofpractice.However,thisisincorrect.NPsareautonomousproviders,regulatedbytheCRNBC,whodonotrequirephysiciansupervision.NPsmayworkindependentlywithotherNPsorasmembersofmultidisciplinaryteamsprovidingfullservicemedicalcareintegratinganursingsciencelenstotheclinicalcareforpopulationsservedandalsoprovideanursingleadershiprolethatPAsdonot.

TheHospitalistroleandtheClinicalAssociate(CA)rolearetwootherroleswithinB.C.(usuallyfundedthroughthePhysicianMasterAgreement)thatareoftennotwellunderstood,andwhichoverlapwithspecialtyNProles.InB.C.,CAsaretypicallyfullylicensedphysicianswhoaremedicalstaff,butnotthemostresponsibleprovider(MRP).Forexample,aCAmaysupportasurgicalgroupbydoingallin-hospitalconsultsorpostoperativemedicalcareorprovidethedaytodaymedicalcareofneonatesinaNICU.InB.C.,theroleoftheHospitalististoprovidegeneralmedicalcaretopatientswhoareinthehospital.TheygenerallyworkalongsideconsultantstocreateamedicalteamandusuallyfunctionastheMRPduringthehospitalization.BoththeCAandHospitalistrolearecurrentlyfilledbyphysiciansandarethereforefundedthroughthephysicianmasteragreement.ItisimportanttonotethatNPsintheU.S.functionasHospitalistsandtherearesomerecentexamplesofNPsworkinginthiscapacityinB.C(InteriorHealthAuthority).Thisisagoodexampleofidentifyinganorganizationalpriority,patientneed,andaservicegapincaredeliveryandaligninganappropriateprovidertofillthisfunction,regardlessofprofessionaldesignationtoachievethegoalsofcareandimprovesystemresponsiveness.

Theimportanceofroleclaritycannotbeoveremphasized.Overthelastdecade,significantinroadshavebeenmadeandthoseprofessionalswhoworkwithoralongsideNPsfullyunderstandtheclinicalroleNPsprovide.ShiftingthefocustoservicesdeliveredbyaprovidergrouplikeNPsisakeyculturalchangethatmustoccur.Doingawaywithout-datedhealthcarehierarchyiskeyincreatingandfacilitatingopportunitiesforinterdisciplinaryteamstoworkcollaboratively,experiencecomplementaryteammemberskillsets,andbenefitfromtheexpertiseoftheNPwithrespecttothefullrangeofservicestheNPprovidesincludingexpertclinicalcare,advancedknowledge/skills/decision-making,clinicalservicedelivery-strategicevaluationofunmethealthcareandhealthserviceneeds;teamfunctioning,systemdesignandresearch.

9.Recommendation:DevelopandImplementanNPRoleClarityCampaignTheMOHandtheNursingPolicySecretariatshouldestablishapublicroleclaritycampaignthatcouldincludetelevisionadvertising,busstopadvertising,pamphlets,flyers,posters,andasocialmediacampaign.

AdoptroleclarityrecommendationsasdescribedbyDonaldetal.,(2010)including:

• CreateavisionstatementtoarticulatetheroleofNPsacrossallsettings.

LindaYearwood,NP(F),Hospitalist,OlderAdults–Kelowna,B.C.“AsamemberofacollaborativeNP/PhysicianHospitalistservicedeliverymodel,Iprovidedirectcare,includingshort-termandlong-termplanningofpatientcarewithmembersoftheinterdisciplinaryteamandcoordinatethetransitionsincareincludingthedischargefromhospital.Ilookafteradesignatedsub-setofunattached,sub-acuteandalternatelevelofcare(ALC)patientsontheHospitalistServicecensuswhodonothaveafamilypractitionerinthecommunity,ortheirfamilypractitionerdoesnothaveactiveprivilegesinthehospital,ortheyarereceivingtertiarycarefromoutoftown.NPcareincludes7dayaweekcoverageforapproximately15-18patients/day,includingweekendandstatutoryholidays.CommondiagnosesofNPpatientsinclude:heartfailure,dementia,delirium,COPD,fractures,kidneyinjuries(acuteonchronic)andpalliativecare.NPHospitalistsinIHhavebeengrantedactivemedicalprivilegeswithinthehospital.EvaluationexpectationsoftheroleoftheNPHospitalistinclude:improvedcontinuityofcare;enhancedmulti-disciplinaryandinter-professionalteamplanning;decreasedlengthofstay,decreasedadmissionsandreducedhospitalcosts.”

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• Developacommunicationstrategytoeducatehealthcareprofessionals,thepublicandemployersaboutNProles.

• Attendtointer-professionalteamdynamicswhenintroducingNProles.• Addressinter-professionalisminallhealthprofessionaleducationprogramcurricula.

Legislative,RegulatoryandOrganizationalRestrictionstoNPPracticeTheBCNPArecognizesthatmanybarrierstoNPspracticingtofullscopehavebeenremovedoverthelastdecade,however,numerouslegislative,regulatoryandorganizationalbarriersremaininplace,whichimpactNPsabilitytodeliverfullservicepatientcare.LegislativebarriersmaystillincludetheChangeofGenderDesignationformfortransgenderpatientsundergoinggender-affirmingtherapiesandinterventions,thePersonswithMultipleBarriersform,eventhoughthisisaprecursortothePersonswithDisabilitiesformthathasrecentlybeenchangedtoacceptNPsignatures.SomeorganizationalbarriersincluderestrictionsandlimitsonMRIorderingdespitethisbeinglegislatedandregulatedaspartofNPscopeofpracticeandtheMedicalOrdersforScopeofTreatment(MOST)formwhichisacceptedwithanMDsignaturebutnotanNPsignatureinsomebutnotallHAs(dependingonthelegaladviceprovided)eventhoughtheformitselfacceptsanNPsignature.

10.Recommendation:RemoveLegislative,RegulatoryandOrganizationalBarriersTheMOHandHAsshouldworktoremovealllegislative,regulatoryandorganizationalbarriersby:

• CompilingandmaintaininganactivelistofexistinglegislativebarrierswithactionsforremovalwiththislistavailabletoallNPs.

• Bundlingtherequiredlegislativechangestoenableseveraltogothroughthelegislativeprocesswhenabillthatimpacts(orshouldimpact)NPsisbeingchanged.

• ReviewingandregularlyupdatingtheMSPlistofservicesthatanNPcanordertoensurescopeofpracticechangesarecurrentorremovingitaltogether.

• ProvidingprovincialdirectionfororganizationalbarrierssuchasMRIorderingandtheMOSTformsincollaborationwiththeChiefNursingOfficerleadershipgroup.

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Guiding Principles Anylarge-scalestrategythatincludesaclearvisionandobjectivesrequiresguidingprinciplestoenableafoundationalpurposeanddirection.TheBCNPAfeelsthefollowingareintegraltothesuccessfulimplementationoftherecommendationsoutlinedabove.

Patient-CentredHealthcareservicesaredelivered“aroundtheindividual,nottheproviderandadministration”(B.C.MOH,2015b,p.1).

TheBritishColumbiaMinistryofHealthPatient-CentredCareFramework(2015)promotestheconceptofpatientsandfamiliestakinganactiveroleintheirownhealthinpartnershipwiththeirhealthcareprovider(s),andpatientsandfamilymembersareconsideredanintegralpartofthecareandhealingprocess.Feinberg(2014)suggeststhatfamilymembershavetraditionallybeeninvisibletocaregiversandexcludedfromthecareprocess.Asthecultureshiftstopatientandfamilycentredcare,thetherapeuticrelationshipsforallhealthcareprofessionalswillberedefined.Forpatients’andfamilymembersthissimplymeansarespectforthewholepersonandthefamily’svaluesandchoicesforensuringcontinuityofcare(Bisognano,2009).

Groundedinanursingscienceperspective,NPmodelsofcareplacethefocusofcareonthepatient’sexperienceoftheirdisease,conditionorhealthconcernwithinthecontextoftheirwholelife,ratherthanconcentratingsolelyonthediseaseitself.NPshaveanethicalobligationtoensurethatthevoicesanddecisionsofpatientsandfamiliesarereflectedinthedeliveryofhealthcareservicesandtheircareperspectiveplacestheNPinastrongpositiontoofferexpertiseandleadershipasthisnewapproachtohealthcareunfolds.

InterdisciplinaryandCollaborative“Acutecaredeliverymodelswillsupportcollaborative-relationalinter-professionalcareandwillbefocusedondrivinginterprofessionalteamsandfunctionswithbetterlinkagestocommunityhealthcare”(B.C.MOH,2014b,p.5)

MultidisciplinaryorinterdisciplinaryteamsexistinmanyspecialtysettingsinB.C.today,refocusingtheireffortsoncosteffectivepatient/person-centredcare,andlookingtoimproveaccesstospecializedhealthcareservices,creatingenvironmentstousetherightproviderskillsetchosenfromavarietyofqualifiedhealthprofessionalswhocanbestmeetpatientcareneeds.Modelsofferimprovedaccesstospecialtyorsub-specialtycareforurgentconcerns,appropriatespecializedfollow-upandmonitoring,healthprevention/promotion,andpartnershipswithotherservicesectors.Maximizingtheefficienciesthatcanbefoundwithinasystemthatisinclusiveofallhealthcareproviderssuchasregisterednurses,pharmacists,socialworkers,counsellorsandpsychologistsallworkingtofullscopeofpracticeisanessentialcomponentofinterdisciplinaryteams.Numerousprovidersarerequiredtoimprovethehealthofasinglepatientacrosstheirlifespan.Apower-shifttoamoreegalitariananddemocraticstructureiscriticaltosuccessfultransformation.Allhealthcareprofessionalsinvolvedinthedeliveryofhealthcareshouldworktofullscopeofpracticetomaximizeefficienciesandberecognizedforthecareofthatpatient.Movingawayfrompatriarchalapproachesandhierarchy,relationalteamsworktobuildrelationshipswithpatientsandwithintheteamthatfurtherstheunderstandingaboutindividualandpopulationneeds.Scholle,Torda,Peikes,Han,andGenevro,(2010)andotherssuggestthattotrulybepatient-centred,acareteamwouldnotnecessarilybephysician-led,butwouldallowtheleadertobeselectedbytheteam–whetheraphysician,NP,socialworker,psychologistorothers.Thepatientsareattachedtotheteam,ratherthanasingleproviderandtheteamviewsthepatient/communitythroughmultiplelensesversusthesinglelensthatoftenisone-dimensionalandnotholistic.Attentiontorelationalbasedcareisfoundationaltobuildinghighlyeffectiveteamsthathaveasharedvision,purposeandmandate.Caredoesnotrelyonasingleprovidertodirect–ratheronprocessestoensureformalandinformalcollaboration.

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NPRepresentation“As Advanced Practice Nurses, NPs possess competencies in change management, research, leadership, and clinical care, therefore their expertise and input will be included at all levels of decision-making in order to further effectively utilize the NP role in B.C. (CNPI, 2016, p. 39) NursePractitionersareessentialleaderswithinthecurrenthealthcaresystemandcaneffectivelycontributetohealthcarereformandpolicydevelopment.OpportunitiesforclinicalleadershiprolesincludingDirectorsofclinicalprogramsandDepartmentHeadshouldbeopentoNPs.TheabsenceofNPsinleadershiprolesoratdecision-makingtablesisasignificantcontributortothelackofawarenessofadvancedpracticenursingroleswithinhealthcareorganizationsandthepublic.ThislackofunderstandingactsasabarriertosuccessfulimplementationofNProleintegration(Sangster-Gormley,Martin-Misener,Downe-Wamboldt&DiCenso,2011).UtilizingNPexpertiseatalllevels(clinicalcare,leadership,educationandresearch)hasgreatpotentialtopositivelyimpacthealthcaresystemresponsiveness,leadtoimprovedaccesstohealthcareacrossthespectrumofcare–contributetoimprovedcontinuityofcare,healthierpatientpopulationsandcontributetoanimprovedpatientexperienceofthesystemofcare.

Dr.HalSiden,MD,Children’sHospiceMedicalDirector-Vancouver,B.C“TheNursePractitionerroleinapediatricpalliativecareprogramwithprovincialreachhasbeenafoundationalelementindevelopinganoutreachprogram.Supportingfamilieswhomovetheircarebetweenaninpatienthospiceunit,hospitalandcommunityrequiresahighdegreeofskillincoordination.Furthermore,whenwesaycommunitywereallyarereferringtobothservicesthataredistributedincommunitiesacrossprofessionalsandagencies,andtocareprovidedbyfamilydirectlyintheirhome.Thematrixofcareishighlycomplex.

TheNPbringsbothastrongsenseofdevelopingapathwayforfamiliesinthiscomplexenvironment,combinedwiththeabilitytoprovidedirect,hands-oncarethroughassessment,treatment,counselling,problem-solvingandsupport.”ItisnotpossibletoimaginedevelopingandexpandingastrongoutreachmodelwithouttheNProle.”

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Summary of Recommendations 1. DevelopaSustainableSalary-BasedNPFundingFramework

2. Develop,AdoptandImplementaQualityAssuranceFramework

3. DevelopaWorkingGrouptoReviewandUpdateNPRemuneration

4. DevelopaHealthHumanResourcesStrategytoNPDeployment

5. EmployNPsandIncreaseEducationalSeatsAccordingtotheHHRStrategy

6. ReviewandUpdateNPEducationinB.C.toReflectPopulationNeeds

7. DevelopNPPostgraduateFellowshipPrograms

8. AdoptaNPProfessionalPracticeFrameworktoEnableaStandardizedApproach

9. DevelopandImplementanNPRoleClarityCampaign

10. RemoveLegislative,RegulatoryandOrganizationalBarriers

ElizabethLeonardis,NP(F),HomeCare-Vancouver,B.C.“Iamamemberofaninterdisciplinaryspecializedteam,whoprovidehomebasedhealthcareforcomplexfrailseniorswhoarelivingathome.Oneofmypatientsisan89-year-oldmanwithmoderatedementia(newlydiagnosed),severecongestiveheartfailure,significantcoronaryarterydiseaseandchronickidneydiseasehaschosentocontinuetolivingonhisown,inhishome.Hehadnumeroushospitalizationsforsymptomaticheartfailurepriortoourteam’sinvolvement.Thepatientwasveryclearthathewantedtostayinhishomeanddidnotwanttogotoresidentialcare.Iprovidedlongitudinalprimarycare,managingthisfrailseniors’chronicdiseasescompetently,whilesupportinghiswishestoremaininhishomeuntiltheendofhislifetherebypromotinganenhancedqualityofcare.Workinginpartnershipwithhiscommunityhomehealthteamandfamily,myselfalongwiththesupportofmyteam,managedtokeepthepatientoutofhospitalforthelastsixmonthsofhislife,toinstitutepalliativecareandcaregiversinthehomeandeventuallytosupporthistransfertohospicewherehepassedpeacefullyaweeklater.”

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Summary InBritishColumbiatoday,40percentofNPsarepracticingacrossthehealthcaresysteminawiderangeofspecialtyroles.TheseNPshavedemonstratedtheirvaluetotheteam,theirpatientsandthesystematlarge,andyettheyremainlargelyoverlookedbyhealthcaredecision-makers,andtheplanninginfrastructureofboththeMOHandlocalHealthAuthorities.Atthesametime,theliteratureshowsthatspecialtyNPscanprovideenormousbenefitsintermsofimprovedaccesstocareforpatients,increasedefficiencieswithinthesystemandoverallhealthcaretransformation(Lowe,Plummer,O’Brien&Boyd,2012).

DecisionmakersinBritishColumbiaarerealizingtheimportanceofintegratingNPsmorefullyintoprimaryhealthcare.Thisisanimportantstepfortheprovince,however,thisfocusdeniestheneedsoftheincreasingnumberofBritishColumbianswhorequireon-goingspecialtyorsub-specialtyservices,doesnotaddressthegapsinpatienttransitionsacrosshealthcaresectors,doesnotanticipatethefutureneedsofouragingpopulationorconsiderthe40percentofNPswhoarealreadyimprovingbothpatientandhealthcaresystemoutcomesinspecializedroleswithhighlyspecializedpopulations.

NursePractitionersshouldbewidelyintegratedacrossthewholehealthcaresystemincludinginacute,ambulatoryandresidentialcarespecialtysettings.Thisdiscussionpaper,anditssubsequentrecommendations,providethefoundationalrequirementsthatwillensurethatspecialtyNProlessupportMOHgoalsandobjectivesandHAorganizationalprioritiesprovidingpatientswithhighqualityhealthcare,improvedpatienttransitionsandhealthoutcomes,improvedteamfunctioning/efficienciesandwillprovideaddedvalueforthesystemasawhole.TheseimportantNProlesarefillingexistinggapsincareandshouldbesupportedandencouragedasfundamentaltothecontinuumofcareaswellasimportanttothedeliveryofspecializedcare/serviceswithinatransformedandintegratedpatient-centredhealthcaresysteminBritishColumbia.

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Glossary of Terms

ClinicalAssociate

Theroleoftheclinicalassociateisnotwelldefined,norunderstood.Aliteraturereviewdemonstratedthatbothlocallyandgloballythetermisusedtodescribeanumberofdifferentarrangementsthatincludeaprofessional(nurse,physician,physicianassistant,occupationaltherapist,etc.)inasupportiveroleintheclinicalsetting(Chittleetal.,2016;Doherty,Conco,Couper,&Fonn,2013).TheCanadianMedicalAssociationreportsnosingulardefinitionofthisroleinthemedicalmodel,andindicatesthatthisrolemaybebetterunderstoodbylookingattheroleofthephysicianassistant.

Nonetheless,theroleoftheclinicalassociatedoesexistinB.C.,andistypicallyemployedinthehospitalsetting.Clinicalassociatesarerecognizedasmedicalstaff,andareguidedbythemedicalbylaws.ClinicalAssociatesarefullylicensedphysicianswhoarenotthemostresponsibleMRPbutwhomanagepatientcareinconsultationwithorunderthedirectionoftheattendingMRP.

ClinicalNurseSpecialistThisadvancedpracticeroleinvolvesanalyzing,synthesizingandapplyingnursingknowledge,theoryandresearchevidencetofostersystem-widechangesandadvancenursingcarethroughoutthesystem.TheCNSisaregisterednurse(RN)whoholdsagraduatedegreeinnursingandhasahighlevelofexpertiseinaclinicalspecialty.Areasofspecializationmayfocusonexpertiserelatedtoaspecificpopulation,apracticesetting,adiseaseorsubspecialty,atypeofcareoratypeofhealthproblem.TheCNSimprovesclient,populationandhealthsystemoutcomesbyintegratingknowledge,skillsandexpertiseinclinicalcare,research,leadership,consultation,educationandcollaboration.TheCNSrolecanchangeinresponsetothedynamicneedsofclients,nursingstaffandpracticesettings,thechangingstrategicdirectionsoftheorganization,andtheeconomicandpolicyprioritiesofhealth-carefundersandministriesofhealth.Despiterolevariability,allCNSworkisaimedatensuringsafety,qualityofcareandpositivehealthoutcomes(CNA,2008;CNA,2009;CNA,2014).

ComprehensiveCareComprehensivecare,isalsoknownasintegratedorseamlesscare,thatfocusesoncoordinatedcareandintegratedformsofcareprovision.Itiscaredesignedtoaddressfragmentationwithinthehealthandsocialservicessystems.TheWHOdefinescomprehensiveorintegratedcareasaconceptthat"bringstogetherinputs,delivery,managementandorganizationofservicesrelatedtodiagnosis,treatment,care,rehabilitationandhealthpromotion.Integrationisameanstoimproveservicesinrelationtoaccess,quality,usersatisfactionandefficiency”(Groneetal.,2002).

Fellowship

Afellowshipforthepurposesofthispaper,isdefinedasapostgraduatespecialtyorsub-specialtyeducationalprogramdesignedtoprovidethefullylicensedNPwiththeappropriatetheoreticalandclinicalcompetenciestoprovidecareforspecialtypopulationsorinspecializedpracticesettings.TheseprogramsofferopportunitiesfortheNPtoacquireadditionalexpertiserelatedtoaspecificdisease/chroniccondition(e.g.,cardiacdisease,addictionsmedicine,palliativecare,trauma,mentalhealth,etc.)oraspecializedpopulationofpatients(e.g.,frailelderly).

HospitalistTheroleofthehospitalist,typicallyaphysician,istoprovidegeneralmedicalcareto“orphaned”hospitalizedpatients(McGowan&Nightingale,2003).Thesepatientsareoftenwithoutahealthcareproviderorhaveaprimarycareproviderwhodoesnothaveadmittingprivileges.Increasinglythehospitalistroleisreplacingthepreviousdoctorofthedayprogramthusprovidingmoreconsistentcarefor

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hospitalin-patients.Thehospitalisthasauniqueskillsetinthattheydealwithbothacuteandchronicillnessandassociatedmultisysteminvolvement.Withtheever-increasingnumberofinpatients,thedecreasingnumberoffamilyphysicianswithadmittingprivileges,increasedacuityofindividualsanddecreasinghealthcarebudgetstherearemulti-factorialreasonstoaccentuatehealthcareteamswiththesehighlyskilledindividuals.

InterdisciplinaryCollaborativeTeamsInterprofessionalorinterdisciplinarycollaborativeapproachesinhealthcareareknowntoimproveaccesstothemostcommonlyneededhealthandsocialservices.Collaborativepracticeoccurswhenhealthworkersfromdifferentprofessionalbackgroundsoffercomprehensiveservicesworkingwithpatients,theirfamilies,caregiversandcommunitiestodeliverthehighestqualityofcareacrosssettings.Practiceincludesbothclinicalandnon-clinicalhealthrelatedwork,suchasdiagnosisandtreatment,surveillance,healthcommunications,managementandservicedesign.

Collaborative,interdisciplinaryteamsarepatient,notprovidercentred,responsiveandflexiblytailoredtomeetthechangingneedsofpatientpanelsorpopulationsbasedonup-to-dateneedsassessments.Teamsorgroupscanbestructuredinmanywaysincludingaco-locatedoracentrallylocatedteamthatrespondtohealthcareneedsforpatientsinsharedclinicalspaces,atoutsidehealthappointmentsorinthehomeorcommunitysetting.Appointmentstructuresareflexibleandmayincludetelephone,telehealthorvirtualappointmentswithteammembers,withtheaimofprovidingpatient-centredcareutilizingthecorrectprovider,atthecorrecttime,inthecorrectplace.Caremaybeprovidedbyoneormoreteammembers,toindividualsorgroups,basedonpatientneed.Leadershipandgovernancesupportsoptimalteamfunctioningandpatientfocusisnon-hierarchical,safe,respectfulandinclusive.Leadershipresponsibilitiesaresharedandrotated.

Patient-CentredFrameworkPatient-centredcareisthefirstofeightprioritiesoutlinedintheMOH’sstrategicplan,SettingPrioritiesfortheBCHealthSystem(B.C.MOH,2014b).Theframeworkoutlinestheelementsofpatient-centredcarethatarebuiltaroundtheindividual,ratherthantheserviceprovideroradministration/agency.TheMOHintendsitsPatient-CentredFrameworktodrivepolicy,servicedesign,trainingandaccountability.

PhysicianAssistantPhysicianAssistantsarehealthcareproviderswiththeknowledge,skillsandattributestoundertakedelegatedmedicalservicesandareidentifiedas“aphysicianextenderandnotanindependentpractitioner;theyworkunderthedirectionofsupervisingphysicianswithintheclient/patient-centredcareteam”(CanadianAssociationofPhysicianAssistants,2011).

PopulationHealth

Populationhealthisdefinedas“anapproachthataimstoimprovethehealthoftheentirepopulationandtoreducehealthinequities,lookingatandactinguponthebroadrangeoffactorsandconditionsthathaveastronginfluenceonourhealth”(GovernmentofCanada,2012b).Populationhealthapproachesrecognizethathealthisacapacityorresourceratherthanastate,moreinlinewiththenotionofbeingabletopursueone'sgoals,toacquireskillsandeducation,andtogrow.Thisbroadernotionofhealthrecognizestherangeofsocial,economicandphysicalenvironmentalfactorsthatcontributetohealth.Thebestarticulationofthisconceptofhealthis"thecapacityofpeopletoadaptto,respondto,orcontrollife'schallengesandchanges”(GovernmentofCanada,2012b).

QuaternaryCareQuaternarycareissometimesanextensionoftertiarycareinreferencetoadvancedlevelsofmedicine,whicharehighlyspecializedor“subspecialized”(e.g.Neonatologist,DevelopmentalPediatrician,Neuro-

40

Oncologistetc.)andnotwidelyaccessed. Experimentalmedicineandsometypesofuncommon diagnostic or surgicalproceduresareconsideredquaternarycare.Theseservicesareusuallyonlyofferedinalimitednumberofregionalornationalhealthcarecentres.Aquaternarycarehospitalmayhavevirtuallyanyprocedureavailable,whereasatertiarycarefacilitymaynotofferasub-specialistwiththattraining.

RelationalBasedCareRelationalbasedcareisfoundationaltoeffectiveteams;itrequiresthecommitmentbyallclinicalteammemberstorecognizeandrespecteachdiscipline’suniquescopeofpracticeandcontributiontotheteamandthepatient.Teammembersworktobuildrelationshipswithintheteamthatfurthersunderstandingaboutindividualpatientsandpopulationneeds.Thepatientbenefitsastheteamviewsthepatient/communitythroughmultiplelensesversusthesinglelensthatisoftenone-dimensionalandperceivedaswellintentionedbutnotholistic.Innovationwithintheteamispromoted.Attentiontorelationalbasedcarecanbefoundationaltobuildinghighlyeffectiveteamswhohaveasharedvision,purposeandmandate.Caredoesnotrelyonasingleproviderdirectingcare;rather,thereisaprocesstoensureformalandinformalcollaborationexists(CreativeHealthCareManagement,n.d).

SecondaryCareNecessaryacutecaretreatmentdeliveredforashortperiodoftimeforabriefbutseriousillness,injuryorotherhealthcondition,e.g.Post-surgical,orEDcare.Italsoincludesskilledattendanceduringchildbirthintensivecare,andmedicalimagingservices.Theterm"secondarycare"issometimesusedsynonymouslywith"hospitalcare".However,manysecondarycareprovidersdonotnecessarilyworkinhospitals,suchaspsychiatrists,clinicalpsychologists,occupationaltherapists,anddentalspecialists.

TertiaryCareTertiarylevelcareisspecializedconsultativehealthcare,usuallyforinpatients orambulatorycarepatientsandprovidedonreferralfromaprimaryorsecondaryhealthprofessional,inafacilitythathaspersonnelandfacilitiesforadvancedmedicalinvestigationandtreatment,suchasa tertiaryreferralhospital.Examplesoftertiarycareservicesare cancermanagement, neurosurgery,cardiacsurgery,plasticsurgeryetc.treatmentforsevere burns,advanced neonatologycare,palliative,andothercomplexmedicalandsurgicalinterventions.

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Appendix A – NP Funding Options

OptionA-HAEmployedAHealthAuthorityseekingtoaddneworadditionalNPstafftomeetanidentifiedneedinacute,ambulatoryorresidentialcarewouldcompletethedesignatedapplicationprocess.ApplicationswouldsupportNProlesthatfocusonincreasingaccesstocareandtransitionsbacktothecommunity.Remunerationwouldincludesalary,fundingforcontinuingeducation,benefits,locumrelief,administrativesupportandcompensationforcallifrequired.FundingwouldbeattachedtotheNPpositionidentifiedintheapplicationprocess,nottheindividualNP.

Thefundingpackagewouldbenegotiatedwitheachapplication.

Fundingcouldbeconsideredfor:

• SingleNPaddedtoanexistingmultidisciplinaryteam

• HAspecialtyandsub-specialtyteamsofNPpracticegroupstoprovidecontinuityofcarebetweenhospitalandcommunitysuchasurgentcarecentres

Foundationalrequirements:

1. TheHAgovernancestructurewillincludeaDepartmentofNursePractitionersthatallowsforafullprivilegingandcredentialingprocess,includingtheabilityfortheNPtobeMRP(includingadmitanddischargeprivileges)whereitisinthebestinterestofthatpatient.

2. TheNPDepartmentHeadwillbeanNPandsituatedwithintheorganizationalstructureofnursingwithadirectrelationshiptotheChiefNursingOfficer.ThiswillensurethestrategicalignmentofNPswithinnursingtopromoteastrongcollectivenursingvoice.

3. Allnon-salarysupportswillbecentralizedundertheNPDepartmentHead.

4. AProfessionalPracticeFrameworkwillprovidethefoundationforroledevelopment,implementationandevaluationandtheNPDepartmentHeadwillbeincludedinalldiscussionsaboutintroducingnewNProles(SeeToolkit).

5. TheHANPreportingstructurewillreflectthescopeofNPpractice,levelofresponsibilityandeducationandataminimumreporttotheDirectorlevel.

6. Astandardjobdescriptionwithabilitytoindividualizecomponentstoreflectthepracticesetting.

7. AstandardremunerationapproachforNPsthatincludeslocumandcallcoveragewillensurepayequitybetweenbothoptions.ItwillalsoensureeffectiverecruitmentandretentionofNPsworkinginbothoptions.

8. TheNPintheroleunderstandsthebudgetfortransparencyandaccountability.

9. Aqualityassurancestrategyasoutlinedinthispaperthatincludesoutcomestoensureaccountabilityforthefunds.

10. NPencountercodeandICD-9reportingwillcontinue,bereadilyavailableforqualityassuranceandbecomepartoftheongoingevaluationoftherole,augmentingotheroutcomemeasurementsasrequired.

11. ExistingspecialtyteamsmustdemonstratepracticereadinessfortheNPincludinganunderstandingoftheroleaswellasensuringthatappropriatesupportsareinplacethatmayincludeofficespace,anexistingexamroomoraccesstoaMedicalOfficeAssistant(MOA).

12. Aformalmentorwillbeassigned.

13. Animplementationconsultantforallapplications.

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Appendix B OptionB-HAAffiliatedThisoptionwouldincludeabilityforgroupswhoworkinthehealthcaresectorthatarenotapartofthehealthauthoritiesbutaffiliatedthroughtheirspecialistservicestoaccessfundingforNProles(e.g.,privateresidentialcarefacilities,mentalhealthandaddictionstreatmentprogramsetc.).The“nurse-in-practice”modelisagoodexampleofthisoccurringinprimarycaresettingscurrentlywhichcouldbeadaptedtospecialtycare(GovernmentofB.C.,2017).

ApplicationswouldsupportNProlesthatfocusonincreasingaccesstocareandimprovedtransitionsbacktothecommunityorinthecaseofresidentialcareNPs,keepingcareinthecommunityandoutofhospital.Remunerationwouldincludesalary,fundingforcontinuingeducation,benefits,locumrelief,administrativesupportandcompensationforcallifrequired.FundingwouldbeattachedtotheNPpositionidentifiedintheapplicationprocess,nottheindividualNP.

ThefoundationalrequirementswillpositiontheNPtolinkbackorbeaffiliatedwiththeHAforprofessionalpractice,continuityofcareandaccountability,ensuringanetworkofNPsratherthanoneNPworkinginisolation.Thismodelwillalsoencouragestandardroledevelopment,implementationandremunerationinalignmenttotheHAEmployedModel.

Thefundingpackagewouldbenegotiatedwitheachapplication.

Fundingcouldbeconsideredfor:• NPswithinPrivateResidentialFacilities

• NPswithinSpecialtyHumanitarian/Non-GovernmentalOrganizations

• NPswithinSpecialtyCommunityOrganizations

• NPswithinSpecialtyPrivatePhysicianOffices

Foundationalrequirements:

1. AformalrelationshipforeveryHAaffiliatedNPpositionwherebytheNPisincludedintheDepartmentofNPstructurewithinthelocalHAthatincludestherequirementslistedabove.

2. AProfessionalPracticeFrameworkwillprovidethefoundationforroledevelopment,implementationandevaluationandtheNPDepartmentHeadwillbeincludedinalldiscussionsaboutintroducingnewNProles(SeeToolkit).

3. TheNPreportingstructurewillreflectthescopeofNPpractice,levelofresponsibilityandeducation.

4. Astandardjobdescriptionwithabilitytoindividualizecomponentstoreflectthepracticesetting.

5. AstandardremunerationapproachforNPsthatincludeslocumandcallcoveragewillensurepayequitybetweenbothoptions.ItwillalsoensureeffectiverecruitmentandretentionofNPsworkinginbothoptions.

6. TheNPintheroleunderstandsthebudgetfortransparencyandaccountability.

7. Aqualityassurancestrategyasoutlinedinthispaperthatincludesoutcomestoensureaccountabilityforthefunds.

8. NPencountercodeandICD-9reportingwillbemandatoryandbecomepartoftheongoingevaluationoftheapplication,augmentingotheroutcomemeasurementsasrequired.

9. Existingpracticesand/orcommunitiesmustdemonstratepracticereadinessfortheNPincludinganunderstandingoftheroleaswellassupportsavailablethatmayincludeofficespace,anexistingexamroomoraccesstoaMedicalOfficeAssistant(MOA).Thiswouldbenegotiatedwitheachapplication.

10. Aformalmentorassigned.ThiscouldbeestablishedbythelocalDepartmentofNPsorwiththeBCNPA.

11. Animplementationconsultantforeachapplication.

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Appendix C – Estimated Budget

PleaseNote:ALLCOSTINGISESTIMATED.ProposedNPsalarywasa)determinedbasedonanationalenvironmentalscanfollowingextensiveconsultationwithBCNPs,b)recognizesthefunction/responsibility/practiceoftheNPproviderandc)promotesimprovedrecruitmentandretention.ThisexampleestimatesthefundingrequiredforasingleNPattheaverageNPsalarytobeaddedtoanexistinginterdisciplinaryteamforeitherOptionAorB.Eachsituation,region,communityisuniqueandlineitemswillrequireadjustingaccordinglywithadditionalitemsaddedbasedonneed.

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Appendix D – Quality Assurance Framework- Example

MOHGoals(Alignedw/CIHI)

CurrentMOHObjectives

HAGoals&Objectives(VCHAServicesPlan-

Example)

ProgramPerformanceMeasures

Outcomes/IndicatorsLogicModelBased

Acceptability Patient-centred Embedpatient-centredpracticesinthedeliveryofallcareandservices.

Programspecificperformancemeasures:Patientsareincludedatcaseconferences

PatientSatisfactionSurveyTeamSatisfactionSurveyNPvisit/pt#’sdata

Accessibility Accesstoarangeofcarewhenneeded.

ExpandpartnershipswithFirstNationsCommunities:KnowledgeexchangeServicelinkages

TimelyAccesstoFullServiceNPSpecialtyCare!improvedteamaccess.Timelyaccesstoinformation(PCP-SCPteam)ProgramspecificperformancemeasuresHoursofoperationOutreachservicesTelehealth

ReferraldataWaitlistdataPt.datarelatedtohomecommunity

Appropriateness Highqualitycare

Shifttointerdisciplinaryteamsdeliveringintegratedcare.

ProgramspecificperformancemeasuresBestPracticeGuidelinesNSQIPprogram

NPEncountercode/ICD-9codesDiagnosticsutilizationdata

Safety SafeCare ProvidequalitysurgicaloutcomesEnabletheexchangeofpatientinformationacrossserviceareas.

BestPracticeGuidelines

Prescriberdata

Effectiveness Improvedpopulationhealth

Improvethehealthoutcomesofthepopulationsweserve.Embedbestpracticesinresidentialcare.

ProgramspecificperformancemeasuresBestPracticeGuidelines

PatienthealthoutcomesChilddevelopmentaloutcomesPt.qualityoflifelivingwithchronicillness

Equity Servicerecognizeindividuals

Services/informationisavailableinpreferredlanguage.

Programspecificperformancemeasures

Populationdemographicdata

Efficiency Transitionsareseamless

Improveaccessforsurgicalpatientstoscreening.

ProgramspecificperformanceMeasuresBestPracticeGuidelines

AppointmentwaittimesUrgentappointmenttimes

Note:AdaptedfromBCMOHGoalsandObjectivesfromtheBritishColumbiaMinistryofHealthServicePlan(2016)retrievedfromhttp://bcbudget.gov.bc.ca/2017/sp/pdf/ministry/hlth.pdfandVCHAServicesPlan2016/2017.Retrievedfromwww.vch.ca/Documents/Service-Plan-2015-2016-Final-October-2015.pdf

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Appendix E – Case Study

OptionA:HAEmployed

SingleNPJoinsaHASpecialtyTeam:CardiacSurgery

GapinCare:Theacutecarecardiacsurgeryserviceisunabletomeettheincreasingroutinecaredemandsforpatientsinhospitalwhorequiresurgicalinterventionforcomplexcardiacdisease.Inaddition,thepreoperativeandpostoperativecareinhospitalandthetransitiontocommunityisdisjointedanduncoordinatedcontributingtoprolongeddischarge,orsubqualityfollow-upcare.

IdentifiedPopulation:Patientsadmittedforsurgicalinterventionforcomplexcardiacdisease.

GoalofCare:Improvedpatientexperienceofcarewhileinhospitalpostcardiacsurgery,improvedpatients/familyknowledgeandself-management,improvedteamabilitytorespondtoandmanagepostoperativecareneedsinatimelymanner.Improvedtransitiontocommunityprimarycareproviderondischarge,andconsistent,timelyroutinefollowupcareandimprovedresponsivenesstourgentconcerns.

IdentifiedServicesRequired:Preoperativeacutecaremanagementofchronicconditionsthatimpactcardiacsurgeryrecovery.Post-CCUmanagementofacutecaretrajectoryincludingotherchronicconditionsandtheoversight/coordinationofdischargebacktocommunityprimarycareprovider.Facilitatingtransitionsfromacutetocommunitytocardiacoutpatientfollow-up.Providepointofcontactforacutecarenursingstaffandotherteammembersaswellaspointofcontactforcommunityproviders.

TheNPwillalsoprovidenon-clinicalleadershipactivitiesincludingeducation,qualityassuranceandresearch,supportofnursingstaffandtheimplementationofbestpractice.

RequesterReadinessforNPProvider:

• ThereisaclearunderstandingoftheNProleandscopeofpracticeandteamsupportoftherole.

• Therequestinggroupwillprovideoffice/examroomspace,clinicalequipment,computer,requiredsoftware,printer,andphone.

FoundationalRequirements:AsperthefoundationalrequirementslistedinAppendixA.

Governance:AsHealthAuthority(HA)employeestheNPwillreportasperHAstructures.

Evaluation:AsperAppendixD(mayincludeadditionalmetricsasdefinedbythepracticesettingteam,e.g.,post-operativecomplicationsoraccesstocare).

BudgetRequest:Estimated@$193,744(NPhiredatstartingsalary)asperAppendixC.

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Appendix F – Case Study

OptionB:HAAffiliated

SingleNPJoinsaPrivateSectorResidentialCareFacilityGapinCare:Unmethealthcareneedsforthefrailelderlypopulationlivingataprivateresidentialcarehome.Manyresidentsfacechallengesaccessingbothprimaryandsecondaryhealthcareservicesandhavesignificantmobilityorcognitiveissuessuchthatleavingthefacilityischallenging.Thisiscontributingtosignificantoveruseofpainmedications,thelocalED,poorqualityoflifeandoverallhealthoutcomesfortheresidentsandpoorlycoordinatedpalliativeandendoflifecare.

IdentifiedPopulation:UnattachedresidentsoftheCareCenter>85yearsold,livingwithfrailty,chronichealthand/ormentalhealthconditionsincludingdementia.Therearecurrently200frailelderlylivingin2centerswhodonothaveaccesstoprimaryorsecondaryhealthcare.

GoalofCare:Improvedqualityoflifeandhealthoutcomesforresidentsincludingdecreasethefrequencyofurgenthealthcrisis,andreducedpolypharmacythroughtheprovisionoflongterm,regularassessmentofhealthstatus,diagnosisandtreatmentofhealthconditionsandcoordinatedendoflifecare.

IdentifiedServicesRequired:Enhancedprimaryandsecondaryhealthcarefortheidentifiedgeriatricpopulation,focusingonprevention/healthpromotionandongoingcareandmanagementoffrailresidentswithcomplexhealthconcerns.TheNPinresidentialcarewilldeveloptrustingrelationshipswithbothresidentsandfamiliesandworkcollaborativelyacrosshealthcaresectorsrealizingeffectiveresourceutilization,andensuringtransitionsareseamlessshouldtheyberequired.

TheNPwillprovidenon-clinicalleadershipactivitiesincludingeducation,supportofnursingstaffandimplementingbestpractice.

RequesterReadinessforNPProvider:

• ThereisaclearunderstandingoftheNProleandscopeofpractice.

• Therequestinggroupwillprovideoffice/examroomspace,andclinicalequipment,computerandrequiredsoftware,faxmachine,printer,phone.

FoundationalRequirements:AsperthefoundationalrequirementslistedinAppendixB.

Governance:AspertheemployingagencyinaccordancewiththefoundationalrequirementslistedinAppendixB.

Evaluation:AsperAppendixD(mayincludeadditionalmetrics,e.g.,decreasedcallstoemergencyservices(police/fire/ambulance),qualityoflifemeasures,patient/familysatisfaction,andhealthstatusuniquetoseniors/frailelderly).

BudgetRequest:Estimated@$193,744(NPhiredatstartingsalary)asperAppendixC.

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