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ACC – REQUIREMENTS AND BARRIERS FOR REGISTERED NURSES AND NURSE PRACTITIONERS UNDER ACC’S CURRENT LEGISLATION, REGULATIONS, POLICY AND PROCEDURES |
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| Recommendation 1 ACC align reimbursement for nursing representatives on ACC advisory groups with that of other health professional groups represented on ACC advisory groups to more closely reflect the value of nurses’ contribution. |
3.1.2 ACC Provider Survey
Each year, ACC conducts a survey of health providers about their opinions
of services provided by, and interactions with, ACC. Specifically, the
objectives of the survey are to:
Information is sought in the following areas:
Only 11 percent of respondents identified themselves as nurses. A total of 68.6 percent of respondents identified themselves as working in general practice; 31.4 percent in other areas.
Given that ACC is gradually moving to recognise nurses as independent providers, it is recommended that the Provider Survey include identification of issues by practitioner type to ensure that processes are meeting the needs of nurses. This would also provide ACC with valuable information from nurse providers that could contribute to enhancement of their systems and processes.
Recommendation 2
ACC review the format for the Annual Provider Survey to include nurses as a separate provider group and to include identification of issues by practitioner type to ensure that ACC processes are meeting the needs of nurses and to provide ACC with valuable information from nurse providers that could contribute to enhancement of its systems and processes.
3.2 ACC purchasing decisions
ACC indicates that it is now making the shift to view nursing more clearly
as a separate profession from doctors in terms of purchasing. However,
the way in which ACC determines what services are required from nurses
is still within the developmental stages. ACC considers that it has increased
its interactions with the nursing sector and stakeholders such as the
Nursing Council. ACC has also increased the scope of conferences it supports
within the nursing sector. ACC believes that through these interactions
it is able to engage in discussion within the sector to identify the services
nurses can provide to claimants.
In December 2004, ACC announced it would be providing funding to five registered nurses in 2005 for them to complete their master’s degrees full time in order to apply for nurse practitioner (rural) endorsement. ACC introduced these scholarships to help ensure that ACC claimants in rural areas have access to primary health care services, especially in areas where there is a shortage of GPs. Subsequently, these nurses will be able to provide services to claimants in rural areas where ACC has identified a lack of services. The College considers that these scholarships are vital to the development of the role and recommends that they continue to be offered annually.
Recommendation 3
ACC continue provision of the Rural Nurse Practitioner Scholarships which are vital for the development of the primary health care nurse practitioner (rural) role and for enhancing services for consumers in rural areas. It is therefore recommended that ACC continue to fund these scholarships on an annual basis.
4 BARRIERS IDENTIFIED
Barriers that have been identified which impede nursing service delivery
because of ACC legislation, regulation, policy and processes have been
grouped under the following headings:
4.1 Barriers that impede service delivery
Nurses have indicated that ACC’s purchasing and contracting arrangements
impede their ability to effectively provide adequate and appropriate services
to their consumers.
4.1.1 Purchasing and contracting arrangements
In 1997, ACC established contracts for ‘serious injury’ which
required providers to have at least five members within the team to be
comprised as follows:
This was seen as a significant opportunity for registered nurses to be recognised team members within a multidisciplinary team, and for nurses to be considered ‘equals’ with their health professional counterparts.
However, since then it has become apparent that the process for providers to contract with ACC is expensive, protracted, and onerous.
The level of documentation required is extensive, with very detailed questions regarding the way providers practice. Specific questions are asked regarding how the provider could demonstrate cultural safety (for example) which nurses consider irrelevant to the contract since cultural safety is already part of base competencies introduced by the Nursing Council with the introduction of the Health Professionals Competence Assurance Act (HPCA) and as such is a requirement of registration.
It does not appear that ACC has an auditing process.
Timeframes are very prescriptive, for example, one provider was requested to sign the contract within a 24-hour timeframe or the contract would become void.
It is costly for providers to submit a tender with costs ranging between $5000 and $10,000. The process is lengthy with one provider stating that between submitting its proposal and receiving notification of the outcome 18 months elapsed. In the interim, the provider was not advised of the level of funding ACC would pay for the service to be provided making effective business planning impossible.
One provider with significant experience with ACC, provided anecdotal evidence that many providers are seeking to exit ACC contracts and within business planning processes, plan to expand private business to cover the income lost. This is not an isolated example.
While providers indicated that they considered the needs of their consumers as paramount, those in private business simply cannot afford the time, resources, or funding to enter into contracts with ACC and are therefore seeking to exit provision of the service.
It was always intended that the nurse practitioner role would have varying employment arrangements which would include professionally independent nurse practitioners with no employment relationship with DHBs, PHOs or other primary health care practices. However, the difficulties encountered by current nurse providers of ACC services indicate that the current contracting process makes it impossible for nurse practitioners to provide ACC services independently and viably.
In summary, for nurses in business ACC’s contracting process is a significant barrier, comprising economic viability and potentially encouraging nurse providers to exit provision of the service.
Recommendation 4 – ACC formally review its contracting process with nurses through the establishment of a separate advisory group including representation from nurses currently experiencing ACC’s contracting process, to discuss the issues and resolve the barriers identified.
4.2 Nurse practitioners
“I believe there are a number of ... opportunities for ACC, including
giving nurses a wider role and integrating all primary health care services”
(Rankin, 2005). Despite an indication from ACC that nurses be given a
wider role, barriers persist which particularly affect nurse practitioners
ability to fulfil their roles as intended. Particular barriers for nurse
practitioners that exist as a result of ACC legislation, policy or process
are:
• lack of recognition of nurse practitioners in the Injury Prevention,
Rehabilitation, and Compensation Act 2001 and an inability therefore for
nurse practitioners to certify fitness for work
• lack of recognition of nurse practitioners in ACC’s Treatment
Provider Handbook 2004/05 which states that “overall patient care
should always be managed by the family’s general practitioner”
• reimbursement and funding.
These issues are described in more detail below.
4.2.1 Barriers contained in the Injury Prevention, Rehabilitation,
and Compensation Act 2001
The purpose of the Injury Prevention, Rehabilitation and Compensation
Act 2001 (IPRC Act) is to enhance the public good and reinforce the social
contract represented by the first accident compensation scheme by providing
for a fair and sustainable scheme for managing personal injury (govt.nz
2005). The scheme has, as its overriding goals, minimising both the overall
incidence of injury in the community, and the impact of injury on the
community (including economic, social, and personal costs), through:
The IPRC Act’s principal focus is therefore on simply ensuring the best possible outcomes for sufferers of personal injury.
Currently the IPRC Act does not define nurse practitioners separately from registered nurses. “Nurses” are defined under both the treatment provider and registered health professional definitions. However, there are some functions under the Act that may only be performed by registered medical practitioners or registered specialists. These functions are:
The significance of the restriction of these functions for nurse practitioners is dependent on the nurse practitioners specific area of practice. All of these functions clearly fall within the competencies and scope of the nurse practitioner role and the inability for nurse practitioners to perform these functions are particularly significant for nurse practitioners in the primary health care, occupational health, mental health and disease management specific areas of practice.
Differential diagnosis is fundamental to the nurse practitioner role. Inability for nurse practitioners to assess incapacity for employment in practice means that the client is required to be referred to a medical practitioner for assessment in order to determine incapacity for work. Alternatively, the nurse practitioner would be required to request assistance from a medical practitioner to sign the necessary paperwork. Both of these alternatives are unacceptable solutions for an autonomous practitioner, responsible for his or her own practice, who is unable to fulfil the role as intended. Unnecessary delays and complications for clients are also introduced, who are not receiving the best possible outcomes as intended by the IPRC Act.
The IPRC Act provides for adding an occupational group or part of an occupational group to a treatment provider or registered health practitioner definition, by regulation. This mechanism could be used to separately define nurse practitioners from nurses.
At present, ACC is experiencing operational issues around the consistency and quality of work certificates currently provided by eligible health professional groups and is therefore concentrating on resolving existing issues before considering extending eligibility to nurse practitioners. While the indications are that the legislation will be reviewed in future to incorporate the nurse practitioner role, no timeframe has been set for completion of this work.
Recommendation 5
ACC work together with the Department of Labour and the Ministry of Health to review the Injury Prevention, Rehabilitation and Compensation Act 2001 to address and resolve the restrictions placed on the practice of nurse practitioners and occupational health nurses, in particular to extend access to issuing work certificates to these groups.
4.2.2 Lack of recognition in the Treatment Provider Handbook
2004/05
ACC’s Treatment Provider Handbook 2004/05 (2004) states that “overall
patient care should always be managed by the family’s general practitioner”.
This is a barrier for nurse practitioners practising in scope’s
requiring first contact, such as primary health care. While prescribing
rights for nurse practitioner’s is a separate issue that is yet
to be resolved, there is at least one nurse practitioner who has prescribing
rights. This does not yet recognise the role of the nurse practitioner
and places further limitations on their practice. A reference to the ‘health
professional in the workplace’ may be a more appropriate option.
4.2.3 Reimbursement and funding
Nurse practitioners indicate that funding is a significant issue in relation
to nurse practitioner practice. More specifically, currently ACC reimbursement
for nurse practitioners is not at a level that is appropriate for the
level of practice of a nurse practitioner which often involves in depth
assessment, and can be up to an hour in duration. In addition, the scope
of service provided is somewhat broader than that provided by a general
practitioner, with one nurse practitioner indicating that:
“... recently I have referred someone to a no-smoking clinic (via GP of course), picked up someone who had raised lipids and given dietary advice, advised a ‘pre-diabetic’ about lifestyle changes and admitted via ED a diabetic patient with infected toe who had amputation of toe next day, but would have undoubtedly had foot or more amputated if left ... All these were seen by GPs but problems not picked up or acted on ... ACC are getting a very cheap service!”
(Nurse practitioner, personal communication, 2005).
For example, as of May 2005, there are three nurse practitioners practising in the wound care area of practice. An hour appointment with a wound care nurse practitioner can involve:
Currently, however, nurse practitioners are reimbursed at the same rate as registered nurses at $15 per visit. General practitioners, however, are reimbursed at a rate of between $32 and $38 per visit.
Prior approval is an additional issue identified by wound care nurse practitioners. ACC requires that prior approval is sought for patients attending the leg ulcer clinic as it is not deemed to be an ‘acute’ service. However, it is not possible for nurse practitioners practising in the leg ulcer clinic to receive prior approval, because they are unaware of patients who are ACC claimants, and those who are not prior to them presenting to the clinic. Ethically, nurse practitioners cannot turn away ACC patients because prior approval has not been sought, and because prior approval is not sought for ACC cases, nurse practitioners are then unable to claim reimbursement from ACC. Currently, therefore, these nurse practitioners are providing a service over and above that currently funded by ACC.
ACC is currently piloting a new compression therapy service for leg ulcers in Manawatu, and Auckland which provides reimbursement for nurse practitioners at a higher level than the current standard rate. The pilots end in May 2006. ACC has indicated that it will not be reassessing the level of reimbursement provided to nurse practitioners in this area until the pilots are completed and evaluated.
At a minimum, nurse practitioners should receive the same reimbursement as a GP in order to recognise the advanced level of nurse practitioner practice.
Recommendation 6
In order to support the autonomous practice of nurses and nurse practitioners allow them to fulfil their roles as intended, it is recommended that ACC review direct nursing access to ACC reimbursement and provide direct funding to nurses rather than channelling funding directly to GP employers. It is also recommended that the level of reimbursement be reviewed to recognise the advanced level of nurse practitioner practice.
4.3 Occupational health nurses
A number of barriers have been identified which are specific to occupational
health nurses. These barriers include:
4.3.1 Funding issues
Nurse-related ACC payment is a described as a “huge obstacle”
by occupational health nurses.
Occupational health nurses receive no public funding via either ACC or the Ministry of Health and are either employed by private companies or organisations; or they are self-employed. Approximately half of the members of the Occupational Health Nurses Association are self employed. Because ACC does not recognise occupational health nurses as separate providers they are therefore prevented from accessing funding directly from ACC.
While some occupational health nurses have individual contracts as providers for specific worksite assessments these are rarely in the place that the nurse is already working and are for a specific claimant only.
4.3.2 Lack of recognition of role of occupational health nurse
Occupational health nurses consider that fundamental to the barriers that
exist in terms of ACC is the fact that ACC does not recognise the role
of the nurse and does not fully understand the role of the occupational
health nurse who has a unique role in the understanding of the culture
of the workplace. Occupational health nurses consider that this is common
among a lot of government departments.
Occupational health nurses can apply to ACC to become workplace assessors, however, workplace assessments are only a small part of the role that occupational health nurses are educated and competent to perform.
ACC had intended to pilot an injury management service in Christchurch that would be led by occupational health nurses, however, this pilot has stalled with no indication from ACC regarding when or even whether the pilot will go ahead.
4.3.3 Duplication of occupational workstation/workplace assessments
It appears that there is duplication of workplace assessments
occurring where on occasions, an ACC case manager has sent an occupational
therapist to do a workplace assessment for someone who has already had
one done in the past in the same area by a different provider.
4.3.4 Inconsistency in occupational health nurses involvement
in injury review process and home injury rehabilitation
Occupational health nurses report inconsistency regarding how ACC case
managers include occupational health nurses in the injury review process.
Some case managers do not include occupational health nurses in the rehabilitation
process and sometimes not in the home injury rehabilitation process at
all.
4.3.5 Lack of communication and consultation
Occupational health nurses consider that there is currently a lack of
communication by ACC with occupational health nurses; and that occupational
health nurses are, for the most part, not consulted with by ACC in strategy
development. While the Occupational Health Nurses Association is represented
on ACC’s Nurse Liaison Group, meetings do not allow for consultation
to occur.
A more encompassing consultation process is required.
Recommendation 7
ACC review its consultation process on all strategy development to ensure all nursing organisations, in particular occupational health nurses, are consulted during policy and strategy development.
4.3.6 Inability to issue work certificates
As outlined in section 5.2.1 regarding nurse practitioners, only a medical
practitioner can issue a medical certificate to confirm an ACC claimant’s
need for time off work due to an injury. If a claimant requires time off
work due to an injury, they need a medical certificate from a registered
medical practitioner who records the claimants incapacity details on an:
- ACC45 Injury Claim Form if this is their first visit – this certifies incapacity for the first 14 days
- ACC18 Medical Certificate if an ACC45 has also been lodged. The ACC18 describes how the claimant’s injury affects their capacity for work (Haywood 2004).
Only a registered medical practitioner can complete an ACC18 Medical Certificate.
While nurses cannot certify incapacity for work, they are able to issue certificates for restricted or alternative duties. This has implications not only for nurse practitioners, but also for occupational health nurses.
In 2004, members of the New Zealand Occupational Health Nurses Association were asked about their ability to issue incapacity for work certificates (Haywood, 2004).
“Up until about a year ago I was a rural health provider and sole charge nurse at a country health centre. As a rural health provider I had the authority to sign ACC 45, i.e. first ACC certificates to record the client’s injury and to confirm their right to ACC support. However, I was not authorised to sign the section that stated they weren’t fit for work. That was a bit crazy as I could supply their total health needs but if they needed to be off work they would have an hours drive to the doctor who would also charge ACC for the visit. The client would need to put in a transport claim to ACC!”
“I feel that many “doctor hours” are wasted on injuries and minor sickness that could be totally managed by suitably experienced nurses. This is particularly so in rural areas and in occupational health where many nurses and doctors would have little understanding of the clients work requirements and the logistics of getting to the doctor. How many folk on a limited income have a suitably warranted and maintained vehicle with a tank full of petrol (or the money to buy it – if there’s a garage open) and a driver with time to drive an hour into town, wait around at doctors and pay any excess charges and drive an hour home.”
“It is impractical for general practitioners to visit every workplace of their patients. I believe that it is my role to ensure that the treating practitioner has a good understanding of the type of work completed.”
“Looking at the injuries [in occupational health] surely it takes more expertise to identify the employee who can do alternative duties than it does to say someone can’t work!!”
Suffice to say, this barrier is a significant obstacle for occupational health nurses.
4.4 Rural nurses
A number of specific barriers are faced by rural nurses, particularly
those who service areas with no GP coverage. These barriers relate to
the Rural Practice Agreement, training for nurses, and the PRIME (Primary
Response in Medical Emergencies) Scheme.
4.4.1 Rural practice agreement
The rural practice agreement is a contract between ACC and rural providers
detailing how ACC services will be provided in rural areas.
The rural nurse is frequently the sole clinician actively involved in the care of patients who require ACC treatment. The doctor may not ever see the patient or their injury, provide advice about it, or provide training to ensure that the nurse is competent. However, despite being the sole clinician and first point of contact, the nurse is not able to complete the off work section of the ACC45 and cannot therefore give the patient a copy to take to their next provider to whom the patient may be referred. The form cannot therefore be completed and sent to ACC for processing until it has been signed by a doctor. In addition, if a nurse sees a patient, in the absence of a doctor, who requires ACC treatment the nurse is unable to diagnose.
This process does not recognise the full potential of the nurse’s role, and in particular the advanced role of the nurse practitioner. In addition, the process incurs delays for the patient and is not satisfactory for good patient care.
Secondly, payment is a further issue. A nurse providing care in rural areas does the same work as a doctor would do, however, the revenue is considerably less. Rural nurses are unlikely to ever see the revenue as it goes directly to the owner of the practice or the doctor. It is inequitable that the role is the same, however, reimbursement is less.
4.4.2 Training for nurses
The rural practice agreement requires that nurses are skilled at suturing.
However, training is unavailable for nurses and one rural nurse has indicated
that ‘all the nurses I approached who are suturing are untrained’.
The Waikato Clinical School provides a course for doctors, however, it
does not consider the course suitable for nurses as it includes training
for minor surgical procedures (such as the removal of skin lesions). Approaches
by rural nurses to ACC to discuss and resolve this issue have been unsuccessful.
Rural nurses consider that it would be useful for ACC to check the competency of nurse signatories to the rural practice agreement, in particular where the nurse in practising in areas without supervision. Training could then be provided in assessing and managing sprains, strains, wounds, suturing, bandaging, and strapping (for example). There is a potential for quality issues to arise if interventions are provided by untrained staff.
4.4.3 PRIME (Primary Response in Medical Emergencies)
The PRIME scheme aims to both improve access to appropriate health care
for emergencies in rural areas; and formalise involvement of primary health
care practitioners (doctors and nurses) in emergency response teams in
rural areas. The scheme is jointly funded by ACC and the Ministry of Health
providing emergency care in both accident and non-accident emergency situations.
In many areas, nurses share the on-call roster for provision of PRIME services with general practitioners. In some remote areas there are no GPs immediately available, however, rural nurses are available. While ACC contracts with ‘PRIME service providers’, this essential means ‘medical practitioners’ since in order for registered nurses to be named in the contract, they must be employed by a rural GP. While ACC is beginning to contract directly with registered nurses for the provision of PRIME services in some areas, in other areas registered nurses are providing first level PRIME services but do not contract directly with ACC.
Rural practice agreements require that all nurse signatories have PRIME training; and under the PRIME service specification each new PRIME practitioner must undertake a five-day course initially, and a two-day refresher course every two years thereafter.
There is a low level of compliance with the requirement that nurse signatories undergo PRIME training, and there is no monitoring to ensure training occurs. It appears that the provision of PRIME training programmes is sporadic and not provided consistently across all regions. In some areas, training programmes have not been run for several years. Even in areas where training programmes are provided, practitioners, including nurses, indicate that there is a difficulty obtaining locums in rural and remote areas to release practitioners to attend the training.
Finally, there is the issue of incentives for nurses to complete PRIME training, given the fact that in most areas they are unable to contract directly with ACC to provide services and there is therefore no reimbursement if the nurse does attend an accident. In many cases, rural nurses are committed to provided services to their community because they are able and willing.
5 IMPACT OF REVIEW OF TREATMENT COST REGULATIONS
5.1 Background
On 1 April 2005, the Injury Prevention, Rehabilitation, and Compensation
(Liability to Pay or Contribute to Cost of Treatment) Regulations 2004
came into force setting out what ACC pays or contributes to the cost of
treatment.
The changes to treatment costs that have applied from 1 April 2005 that
may have implications for nursing service delivery are:
1. GP payments – where a claimant sees a GP, the practice may claim
a consultation fee from ACC of:
2. Joint GP/nurse consultation payments – where a claimant sees both a nurse and registered medical practitioner during the same consultation, the practice may claim a joint consultation of:
3. Nurse only consultation payments
5.2 Impact on nursing service delivery
The review of treatment costs did not increase the reimbursement paid
to nurses for consultations which remains at $15 per nurse only consultation
as prior to the commencement of the review.
The changes to the cost of treatment regulations have not differentiated between the role of the registered nurse, and the role of the nurse practitioner. This means that a registered nurse is reimbursed at a rate of $15.00 per ACC consultation regardless of whether that nurse is, for example, a wound care nurse practitioner consulting with a patient for up to an hour including full diagnosis and treatment.
No ‘nurse only consultation payment’ or ‘joint GP/nurse consultation payment’ is paid directly to the nurse, but rather to the general practice, precluding nurses from accessing funding from ACC for this purpose directly. Practice nurses indicate that they consider the treatment cost should be applied to the service or task and not to the provider providing the service. This would allow easier identification of the actual/real value and cost of nursing services and nurses may be adequately remunerated for ACC services, in turn adding value to the practice in financial terms.
As a direct funding source is not yet available for nurses from ACC there is little incentive for existing nurse practitioners to establish their own businesses. A disincentive exists to expand practice nursing services as there is little financial gain and it is uneconomic to do so. Nurses considering becoming nurse practitioners may well be reluctant to pursue endorsement if they are unable to adequately fulfil the requirements of the role because of the barriers presented.
The layered level of payment focusing purely on the provider rather than on the service or treatment “... appears to assume that the service the GP provides is worth more than the PN [practice nurse] as the rate is higher despite the fact that often the PN assesses and manages care, for example wound or plaster care, with minimal input from the general practitioner. This funding encourages professional disempowerment of nurses as GPs often insist on seeing all clients every time to gain the higher fee from ACC regardless of the actual need” (Minto 2004).
Even though ACC includes ‘nurses’ in its definitions of providers, not reimbursing nurses directly as other providers are reimbursed renders nursing services virtually invisible.
By way of background, Cabinet agreed that funding for the treatment cost regulations should consider a framework including:
Direct reimbursement for ACC services must be available to nurses, and in particular nurse practitioners, because:
The implications for increasing reimbursement for nurses would require a budget bid process which would be evaluated on the issues outlined above.
CONCLUSION
ACC has indicated that it is working to view nursing more clearly as a
separate profession from doctors and that work is commencing to identify
how it can identify which services to purchase directly from nurses. Despite
this shift, many barriers for registered nurses and nurse practitioners
exist with respect to ACC policy and procedures.
The single most obstructive barrier that impedes the delivery of nursing services being reimbursement and funding.
Occupational health nurses express difficulty accessing direct funding for ACC and while some have secured contracts, these are rare indeed. Nurses and nurse practitioners in primary health care are unable to receive direct funding for provision of ACC services which is instead paid to the GP or the practice. This implies that nurses are responsible to another profession – doctors – for their practice. In fact, nursing is an autonomous, self-governing profession – a distinct scientific discipline with many autonomous practice features. Nursing is not directed by doctors. In addition to extensive medical expertise, nurses have a unique holistic patient advocacy focus, a unique scope of practice, and a unique body of knowledge.
Nursing autonomy is also positively correlated with better perceptions of quality of care and delivered higher teamwork (Rafferty 2001).
Although there is clearly a significant overlap with medicine, nursing is not a subset of, nor dependent on, medicine. Of course nurses and doctors collaborate as part of the multidisciplinary health care team. However, doctors’ combination of economic power and social status continues to remain unmatched.
The profession of nursing has the authority and responsibility to define its own standards of practice. It is unlikely that any doctors, without having completed nursing education, would be able to offer competent reliable opinion on those nursing standards.
It is therefore recommended that in order to support the autonomous practice of nurses and nurse practitioners, and to allow the profession to practice within its full capabilities and requirements as intended, ACC review direct nursing access to ACC reimbursement, and provide direct funding to nurses rather than channelling funding directly to GP employers.
When implemented, these recommendations will vastly improve the delivery of ACC services via the nursing profession and enhance the outcomes for people who suffer a personal injury.
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