Nurse Practitioners Continue Long Wait for Independence as Nursing Board Deliberates
Gaps in care persist as regulators set terms of AB 890 implementation
By the time nurse practitioner Alexa Colgrove Curtis sees patients seeking help for opioid use disorder, most have endured some combination of trauma, encounters with the justice system, near-death overdoses, and failed attempts to quit using drugs. Curtis remembers one young patient who was filling out the adverse childhood experience questionnaire when she asked if the scale went higher than 10. Like many of the people Curtis cares for in rural Nevada County, California, west of Lake Tahoe, this patient had lived through numerous social and psychological stressors, including using intravenous heroin in middle school. Although she tried to stop, the extreme flu-like withdrawal symptoms made her feel like she was going to die, and her dependence continued.
Curtis, who holds a nursing doctorate and a master of public health, told the patient that medication-assisted treatment would reduce the intense withdrawal symptoms and subsequent cravings and that therapy services and support groups would ease the struggle. “She realized that she wasn’t alone and deserved a good life,” Curtis said, pausing to contain her own emotions. The woman no longer uses drugs and now works at a substance use treatment center where she can help others. Curtis says the severity of the opioid epidemic in western Nevada County continues, and Curtis is alarmed that the demand for treatment outstrips the supply of available health care providers, including nurse practitioners (NPs).
While studies have shown that NPs in California are more likely than physicians to accept uninsured or Medi-Cal patients, their ability to serve more people hinges on implementation of a state law enacted in September 2020. Historically, NPs in California have been required to work under the supervision of a physician — a major hurdle in rural communities that attract and retain few doctors, Curtis said. The new legislation, AB 890, allows NPs to work without supervision after a three-year transition to practice, but the transition regulations and effective date are yet to be decided.
Nurse practitioners are critical to addressing the primary care provider shortage that existed before COVID-19.
California Health+ Advocates
Though lawmakers chose to increase access to NPs with the new law, all eyes are now on the state Board of Registered Nursing as it works to implement AB 890. Advocates of the legislation are concerned that this process has been sluggish.
A Need for Rapid Implementation
“AB 890 regulations are taking longer than expected,” said Andie Martinez-Patterson, senior vice president of government affairs with CaliforniaHealth+ Advocates. “Nurse practitioners are critical to addressing the primary care provider shortage that existed before COVID-19. The gap continues to widen, especially in rural and urban communities with unmet medical needs, who are the hardest to reach and experiencing a disproportionate impact of the virus.”
“Before nurse practitioners can start practicing without physician supervision, the Board of Registered Nursing must facilitate the process to implement changes to the current system,” said Garrett Chan, PhD, NP, president and CEO of HealthImpact, an organization focused on increasing the nursing workforce. “Rapid, responsible implementation will increase access to quality care for Californians.”
The board will make decisions about numerous details, such as whether California NPs who hold national certification must pass an exam before they can practice without physician supervision. Twenty-eight states and Washington, DC, now allow NPs to practice without physician oversight after licensure or after a transition period, but California NPs won’t have the right to do this until the board completes the implementation process.
House Calls for Seniors at Home or in Residential Facilities
Nurse practitioners who work with older adults share Chan’s sense of urgency. “We have more patients than we can handle,” said Ron Ordona, a doctor of nursing practice who serves homebound seniors in the Sacramento area. In 2013, he founded Senior Care House Calls with a team that includes a consulting physician and two other nurse practitioners.
While 80% of Ordona’s house calls are focused on follow-up care — refilling medications, drawing blood to monitor chronic conditions, and the like — other visits are related to new symptoms that require testing. For example, when Ordona visits a patient with shortness of breath, he can write an order for a mobile x-ray machine to be brought in to make images that frequently reveal pneumonia that can be treated with antibiotics. This keeps the condition from growing severe and helps patients avoid preventable hospital admissions or emergency room visits.
Ordona also is called upon by assisted living facilities to provide services when physicians are not on-site. One facility recently called Ordona late on a Friday afternoon because a woman with dementia had been discharged from a hospital without a physician’s report. The assisted living facility couldn’t accept her as a resident without this paperwork, and sending her home with family members would be unsafe. The family was relieved when Ordona arrived to assess the patient and complete the needed paperwork.
Supply Misaligned with Demand
Like Ordona, Charlotte Gullap-Moore, DNP, a nurse practitioner in Santa Barbara who provides primary care for adults and geriatric patients, has seen how patient care for the elderly suffers from the dearth of providers. More than nine million California residents are projected to be over 65 years old by 2030 — an increase of more than three million in 10 years– yet the state had only 736 certified geriatricians in 2018.
When Gullap-Moore started working in 2016 under the supervision of a chief medical officer overseeing several nursing homes, she discovered that many patients were taking medications that were no longer necessary. She also noticed that many had been discharged from hospitals without important health information, such as the last time patients had received pain medication and directions for providing wound care. She worked to improve patient management in ways that reduced the number of falls, infections, medications, and hospitalizations for nursing home residents.
“It was eye-opening to see how important it is to eliminate barriers to care for the elderly, and nurse practitioners are equipped to help meet this tremendous need,” said Gullap-Moore.
Gullap-Moore worries that delaying nurse practitioners’ ability to practice without physician supervision will harm the elderly and other underserved populations in California.
While the state’s pandemic stay-at-home order was in effect, she discovered another niche for NPs by offering patients telehealth services via phone or video. She had joined a medical practice specializing in pain management, and for years, many of its patients had been taking high doses of opioids to treat pain. Although Gullap-Moore knew they needed pain medication to function, she was eager to help people reduce the dosages to lower such risks as liver and kidney damage. It quickly became clear that these patients would need more than the customary 15- or 30-minute medical appointments to reach these goals.
“By taking time to learn about their routines, struggles, and history with opioids, I could create a realistic plan to taper the medication slowly,” she said. One man in his early 70s had taken the drug Norco — a combination of hydrocodone bitartrate and acetaminophen — for years to treat chronic back pain. When his pandemic anxiety surged and sleeping became difficult, he was tempted to increase the daily dosage. After Gullap-Moore learned that he lived alone and had stopped taking showers and brushing his teeth regularly, she connected him with a therapist to treat him for the anxiety. Meanwhile, the NP worked with the patient regularly to set and meet goals for self-care and Norco dosing. After several months, his hygiene improved, and his opioid intake decreased.
Gullap-Moore enjoys supporting older adults who are homebound or reside in nursing homes — experience that has revealed many patients not receiving the care they need. She worries that delaying nurse practitioners’ ability to practice without physician supervision will harm the elderly and other underserved populations in California.
“Physicians are overextended,” she said. “By allowing NPs to practice to the full extent of their training as soon as possible, we will unleash a large workforce to offer more preventive care, reduce unnecessary emergency room visits, and ultimately help people enjoy better health and wellness.”